Robert Leigh
25 Sept 2023 · Coroner Alan Walsh · Manchester West
The coroner's concerns
1. missed care coordinator visits
“During the period from the 25th of October 2022 to the 4th of January 2023 there were no visits from a Care Coordinator, or a Community Psychiatric Nurse, and all the 2-week planned visits did not take place, so that 4 or 5 visits were missed”
2. lack of interim care coordinator
“There was no appointment of an interim Care Coordinator or a Community Psychiatric Nurse to cover the 2 weekly planned appointments following the absence of YL”
3. duty officer neglect of appointment review
“There was no responsibility on a Duty officer to review planned appointments during the absence of a Care Coordinator and to arrange for a Community Psychiatric Nurse to attend any planned appointments”
4. absence of resilience planning
“There were no resilience plans in place to cover the absence of a Care Coordinator, either in relation to short term or long- term absences”