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recurance

Mohamed Ellaboudy

30 Apr 2024 · Coroner Heidi Connor · Berkshire

The coroner's concerns

  1. 1. care coordination failure

    “systems are in place for sufficiently robust care coordination for patients who have been discharged from a mental health setting, particularly in the context of detained/recently detained patients”
  2. 2. telephone-only appointments

    “Reliance on telephone rather than face to face appointments”
  3. 3. inconsistent MDT meeting schedule

    “Regularity / thresholds for MDT discussions”
  4. 4. family reporting barrier

    “Absence of a clear route for family to report concerns, even where a patient does not wish confidential information to be given to their family”
  5. 5. lack of discharge correspondence

    “Policy / expectation for correspondence with primary care, particularly in the time after discharge from hospital”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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