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Robert Cardwell

23 Jun 2017 · Coroner Rachel Galloway · Preston and East Lancashire

The coroner's concerns

  1. 1. failure to relay non-attendance information to MDT

    “On The 6th July 2016 a nurse at the Trust contacted Mr [name redacted] to find out why he had not attended his appointment with the Psychiatrist that day. Mr [name redacted] told the nurse that he had been unable to attend the appointment because he had no petrol. He also advised that he had no phone credit and had therefore been unable to contact them. Mr [name redacted] reported that his ex-partner had stolen his bankcard and that all the money had gone from his account. The nurse advised that this information”
  2. 2. lack of follow-up after overdose and MDT non-discussion

    “On the 6th August 2016 Mr [name redacted] was seen in hospital by a member of the liaison team following a significant overdose. He was later discharged from hospital and he queried with the HTT on the 9th August 2016 (on attending West Strand House in person) whether he was due a follow-up with the HTT. Mr [name redacted] was told that the MDT would be asked the following day and that someone would contact him from the team to let him know. I found that the message was - on this occasion - relayed by the”
  3. 3. inadequate record keeping and message handling in MDT

    “I am concerned about the process by which messages are relayed from service users to the MDT team. The nurse explained that the information was passed on to be taken up by the Duty Worker and it should then have been reported to the team. The nurse also recorded the contact in Mr [name redacted] clinical record but these were not looked at during the course of the MDT meeting.”

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.

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Robert Cardwell · Recurance