Paul Meadows
29 Jun 2022 · Coroner Peter Taheri · Suffolk
The coroner's concerns
1. inadequate risk assessment and safety planning
“broad issues in relation to thoroughness of risk assessment and safety planning in other cases as well as [the deceased]'s case”
2. inconsistent triage judgement and low professional curiosity about risk
“inconsistencies in judgement of triage scale and the level of professional curiosity around risk and suicidal ideation”
3. inadequate triage and risk assessment due to time constraints
“occasions when First Response Service practitioners did not have enough time to gather the required information and properly to triage and risk assess”
4. funding disparity causing recruitment difficulties
“difficulties in recruitment are associated with differences in funding for the First Response Service between the commissioners for different counties”
5. insufficient time for triage and risk assessment on calls
“practitioners do not always have sufficient time on calls to gather the required information and properly to triage and risk assess”
6. future deaths due to inadequate triage and risk assessment
“risk of future deaths that will occur or will continue to exist in the future”