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
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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
Coroner's concerns
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.
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