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Rory Attwood

10 Dec 2020 · Coroner Caroline Saunders · Gwent
Check this reportOriginal

The coroner's concerns

  1. 1. lack of GP involvement in serious incident reviews

    “[the deceased] had been discharged from acute services and was under the care of his General Practitioner”

  2. 2. gaps in service provision causing patient to fall through

    “charity MIND wrote to me and expressed concerns that [the deceased] had fallen between gaps in services”

  3. 3. absence of primary care involvement in incident reviews

    “it would seem appropriate that the patient's primary care contact (especially when being supervised in the community) be involved in internal /serious incident reviews”

Responses

2021-0086-Response-from-Aneurin-Bevan-University-Health-Board-Redacted.pdf ↗· Aneurin Bevan University Health Board

Stated action · August 2021

“The Mental Health and Learning Disabilities Division is reviewing its processes to ensure that involvement of third sector and other organisations is recorded sooner, thus ensuring that such organisations are also invited to participate when they have been involved in a person's care. This invitation will be sent in letter format as opposed to the pro forma format described above.”
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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