Michelle Jennings
9 Feb 2022 · Coroner Alison Mutch · Manchester South
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. long waiting times for therapy
“The inquest heard evidence that the backlogs for therapy were such that the waiting list at the time she was assessed as being appropriate for step 4 therapy had a two year wait time. Since that time the waiting period had not decreased and was now between 2 -3 years in both primary and secondary care. This was due to a shortage of trained therapists and demands on the service and was a national issue not specific to the CWP trust.”
2. lack of ownership in referral and discharge policy
“The inquest was told that the trust had since [the deceased]'s death recognised that the lack of ownership created through the application of its referral and discharge policy internally carried an unacceptable risk. Significant changes had been made. However it was unclear if nationally the lesson had been shared and that other mental health trusts had taken similar steps.”
3. inadequate consideration of mental health in prosecution decisions
“The evidence before the inquest was that there needed to be a clear understanding by all prosecuting authorities of the impact of a prosecution on someone with a complex mental health background such as [the deceased]. In [the deceased]'s case the BTP file reviewer (the nature of the offence [the deceased] faced meant that it was not a CPS lawyer who made the charging decision) had not correctly applied the public interest test and had not considered the mental health/vulnerability of [the deceased] as required”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“A target waiting list of 18 weeks is far too long but | was told that this was a funding issue.”
This report
“The inquest heard evidence that the backlogs for therapy were such that the waiting list at the time she was assessed as being appropriate for step 4 therapy had a two year wait time.”
Closely relatedConfidence 0.85 · high
This report
“The inquest heard evidence that the backlogs for therapy were such that the waiting list at the time she was assessed as being appropriate for step 4 therapy had a two year wait time.”
Later report
“Psychological treatment in the form of Cognitive Behavioural Therapy with Exposure Response Prevention had a waiting list of one year;”
Responses
2023-0220-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
Stated action · 2023/24
“we are committed to increasing investment in, and improving access to, mental health services. Under the NHS Long Term Plan1, by 2023/24 mental health services will receive £2.3billion more than in 2018/19, which will mean that 2 million more people will have access to mental health services, including an additional 370,000 adults with severe mental illnesses.”