Source · Prevention of Future Deaths
Mylon Sheppard
Ref: 2019-0025
Date: 17 Jan 2019
Coroner: Sean McGovern
Area: Warwickshire
0 responses identified · 2 indexed addressees
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AI-generated concerns summaryThe coroner identified issues with the oversight of duty worker decisions, the management of waiting lists, and the process for patient non-attendance at the hospital. Concerns were also raised about the inclusion of family in care planning and the lack of a system for identifying service boundaries to ensure correct mental health referrals.
Date
17 Jan 2019
56-day deadline
18 Jul 2019 est.
estimated from the Judiciary.uk publication date
Responses identified
0 of 2
Coroner's concerns
The coroner identified issues with the oversight of duty worker decisions, the management of waiting lists, and the process for patient non-attendance at the hospital. Concerns were also raised about the inclusion of family in care planning and the lack of a system for identifying service boundaries to ensure correct mental health referrals.
View full coroner's concerns
(1) Failure of any effective oversight of decisions made by duty workers (2) Failure to effectively manage waiting lists_ (3) Failure to have a clear process at the Hospital in respect of non attendance of patients (4) Failure to ensure that family members are including are care planning (where the patient is for that to happen).
(5) Failure to have a system in place that clearly identified GP boundaries and geographical boundaries in respect of local mental health services to minimise the risk of incorrect referrals to the wrong teams
(5) Failure to have a system in place that clearly identified GP boundaries and geographical boundaries in respect of local mental health services to minimise the risk of incorrect referrals to the wrong teams
Report sections
Investigation and inquest
5 October 2018 commenced an investigation into the death of Mylon Sheppard 49 vears old. The investigation concluded at the end of the inquest o 17 January 2019. conclusion of the inquest was suicide
Circumstances of the death
Mr Sheppard hanged himself at his home and was found on 3 October 2018. He had significant contact with the Trust from 5 June 2018
Action should be taken
In my opinion action should be_taken to prevent future deaths and believe YOu as Chief On The Day happy
Executive of the Trust have the power to take such action.
Executive of the Trust have the power to take such action.
Similar PFD reports
Report details
- Reference
- 2019-0025
- Date of report
- 17 January 2019
- Coroner
- Sean McGovern
- Coroner area
- Warwickshire
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: 18 Jul 2019 (estimated from the Judiciary.uk publication date).
Sent to
- Coventry & Warwickshire Partnership Trust
- Coventry NHS Trust