Source · Prevention of Future Deaths
REDACTED
Ref: 2022-0095
Date: 28 Mar 2022
Coroner: Sean McGovern
Area: Warwickshire
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner noted concerns regarding the failure to appoint a Care Co-ordinator, which may have contributed to the death. There were also significant staffing shortages in the North Warwickshire area, with levels 65% below recommended as of March 2022.
Date
28 Mar 2022
56-day deadline
23 May 2022 est.
estimated from the report date
Responses identified
0 of 1
Coroner's concerns
The coroner noted concerns regarding the failure to appoint a Care Co-ordinator, which may have contributed to the death. There were also significant staffing shortages in the North Warwickshire area, with levels 65% below recommended as of March 2022.
View full coroner's concerns
During the inquest, the evidence and information revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. i. I am concerned that the failure to appoint a Care Co-ordinator may have contributed to death.
ii. I am concerned that there remain significant staffing shortages in the North Warwickshire area. I heard evidence that staffing was 65% below recommended levels as of March 2022.
ii. I am concerned that there remain significant staffing shortages in the North Warwickshire area. I heard evidence that staffing was 65% below recommended levels as of March 2022.
Report sections
Investigation and inquest
On 13th August 2021, I commenced an investigation into the death of (aged 42 years). The investigation concluded at the end the inquest on 28th March 2022 at Warwickshire Coroners Court.
Circumstances of the death
was found hanging on 25 July 2021 at his home address . On 2nd May 2021, he presented at University Hospital Coventry & Warwickshire with suicidal ideation. He was seen by a Community Mental health Nurse on 4th May 2021. From the 5th May to 20th May 2021 he was given a crisis bed at Harry Salt House. He returned home and was seen regularly by the Crisis Team. On 19th June he was transferred to Community Mental Health Team. He was on a waiting list for a Care Co-ordinator but a Care -Ordinator was not appointed before he died. On 9th July 2021, raised her concerns that a Care Co-ordinator had not been appointed. On 23rd July 2021, telephoned the Mental Health Team in a very distressed state asking why the waiting list is so long and explained that he didn’t have anyone in the Mental Health Team to talk to. He was explained to him that he could go to A&E or call the Samaritans if he felt unsafe.
Similar PFD reports
Report details
- Reference
- 2022-0095
- Date of report
- 28 March 2022
- Coroner
- Sean McGovern
- Coroner area
- Warwickshire
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 23 May 2022 (estimated from the report date).
Sent to
- Coventry and Warwickshire Partnership NHS Trust