Odessa Carey
12 May 2023 · Coroner Andrew Hetherington · North Northumberland and South Northumberland
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. future deaths
“risk that future deaths will occur unless 'action is taken”
2. uncoordinated discharge
“discharge was not a coordinated discharge in line with the trust CPA policy. There was no discharge meeting, no involvement with other agencies or”
3. premature discharge
“discharge from the Community Treatment Team was premature.”
4. inconsistent risk assessment
“inconsistent approach to the assessment of risk.”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“a gentleman hanged himself 2 days after a discharge from the Carleton Clinic when again the Home Treatment Team were expected to take over but not invited to the discharge meeting”
This report
“I am concerned that following discharge from the Lowry ward to the community and prior to discharge from the community treatment team, the deceased was seen only four times in person by individuals from the mental health team and only once by the care coordinator.”
Responses
No published response was found on judiciary.uk.