Shelemiah Peterkin
20 Jun 2024 · Coroner Adam Hodson · Birmingham and Solihull
The coroner's concerns
1. delay in referral to Home Treatment Team
“I heard evidence that there was a 6-day delay in the Community Mental Health Team team making a referral to the Home Treatment Team which was put down”
2. incomplete early warning signs
“I heard evidence from the Structured Judgment Review that a learning point was identified that early warning signs were not completed to the required expectation or standard”