Timothy Reading
21 Nov 2025 · Coroner James Puzey · Worcestershire
The coroner's concerns
1. lack of formal documented s.117 plan
“The absence of a formal documented s.117 plan agreed by all those responsible for a patient's care and treatment upon discharge into the Community from a lengthy inpatient stay creates a risk of disjointed, disorganized and inadequate support for vulnerable people suffering serious mental health conditions”
2. absence of national guidance on s.117 plan components
“I was informed by the Representative of BSMHFT that there is no national guidance from the NHS or other source that explains what a s.117 plan should address”