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Terri Malone

24 Oct 2022 · Coroner Hugh Bricknell · Herefordshire
Check this reportOriginal

The coroner's concerns

  1. 1. inexperienced practitioner making treatment decisions

    “Initial contact with the service is with an inexperienced practitioner and a decision is made regarding a treatment plan without any direct contact being made by an experienced practitioner.”

  2. 2. discharge without confirming circumstances

    “discharged from the service if they fail to attend an appointment and do not respond to a voicemail by the end of the day”

  3. 3. discharge without assessing current circumstances

    “discharge the patient without establishing their current circumstances and the current (if any) input from other agencies”

Responses

2023-0001-Response-from-Herefordshire-and-Worcestershire-Health-and-Care.pdf ↗

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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