Source · Prevention of Future Deaths

John Gogarty

Ref: 2019-0200 Date: 17 Jun 2019 Coroner: Christopher Dorries Area: South Yorkshire (West) Responses identified: 0 / 2 View PDF

A mental health trust failed to follow up and share information with the Probation Service regarding a patient associating with a high-risk individual. This breakdown in inter-agency communication prevented consideration of further safeguards.

Date 17 Jun 2019
56-day deadline 20 Aug 2019
Responses identified 0 of 2
Mental Health related deaths

Coroner's concerns

AI summary
A mental health trust failed to follow up and share information with the Probation Service regarding a patient associating with a high-risk individual. This breakdown in inter-agency communication prevented consideration of further safeguards.
View full coroner's concerns
The MATTER OF CONCERN is as follows. –

Your Trust was solely concerned with the care of . During that care your patient was associating with who had a very considerable history and was under the supervision of the National Probation Service following a sentence for murder. Although original efforts were made to contact the Probation Service to pass on information, these came to nothing because insufficient details about the male were known. However, within a relatively short time further information to identify this male became apparent but there was no further follow up with the Probation Service.

No specific criticism is made of the member of staff involved at that time, it might very well be that many staff might have assumed that there was nothing to be gained. However, in reality, if the Probation Service had been aware of your patients background they would have at least had the opportunity to consider the conditions of the parole afresh, potentially putting in place further safeguards.

It is respectfully suggested that the lesson here is that small pieces of information properly shared on an inter-agency basis might well add up to a bigger picture for other organisations.

Report sections

Circumstances of the death
The circumstances of the death are set out in some detail in the findings and conclusion previously supplied to the Interested Persons but a copy is attached hereto.
Copies sent to
of Mr Gogarty. A copy will also be sent to National Probation Service

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Report details

Reference
2019-0200
Date of report
17 June 2019
Coroner
Christopher Dorries
Coroner area
South Yorkshire (West)

Responses identified

Responses identified 0 of 2
2 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 20 Aug 2019.

Sent to

National Probation Service
RDaSH NHS Trust

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