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Nicola Norman

14 Mar 2023 · Coroner Fiona Wilcox · Inner West London
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The coroner's concerns

  1. 1. lack of discussion with supervising clinician

    “SPA contacts are not routinely discussed with a supervlsing clinician, ss should have but did not happen in Ms [name redacted] case, where mental health symptoms and especially where suicidality is raised by the caller”

  2. 2. lack of referral to qualified clinician

    “such calls are not routinely passed on to a suitably qualified cliniclan able to undertake mental health assessment and assess risk for the patient”

  3. 3. lack of notification to GP and mental health services

    “SPA contacts are not routinely notified to the patient's GP and any mental health services providing care for the patient”

Responses

No published response was found on judiciary.uk.

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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.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error