Suzanne Ellerby
14 Nov 2025 · Coroner Anna Loxton · Surrey
The coroner's concerns
1. lack of follow up of vulnerable patients after transfer
“Vulnerable patients are often transferred back to primary care by mental health services for their onward care, which is effected by way of a Discharge Letter”
2. absence of guidance for follow up
“NHS England has not provided any guidance in respect of expectation for follow up by primary care services when this transfer takes place”
3. vulnerable patients bear responsibility for follow up
“In the absence of such guidance, the onus is on vulnerable patients to ensure they follow up their care with their GP, without any safety netting in place should they fail to do so”