Source · Prevention of Future Deaths
John Derwent
Ref: 2018-0171
Date: 4 Jun 2018
Coroner: Alison Mutch
Area: Manchester (South)
0 responses identified · 2 indexed addressees
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AI-generated concerns summaryThe coroner noted significant waiting times for CBT, reaching 12 months against a 6-week target due to insufficient capacity. The report also described ineffective escalation mechanisms between the commissioning body and service provider to address the increasing waiting list.
Date
4 Jun 2018
56-day deadline
2 Sep 2018 est.
estimated from the Judiciary.uk publication date
Responses identified
0 of 2
Coroner's concerns
The coroner noted significant waiting times for CBT, reaching 12 months against a 6-week target due to insufficient capacity. The report also described ineffective escalation mechanisms between the commissioning body and service provider to address the increasing waiting list.
View full coroner's concerns
The Inquest heard that the target time for an appointment for CBT should be 6 weeks. At the time Mr Derwent was referred, the waiting time was 12 months. There was a waiting list review in October 2017 when it was established that 500 people were on the waiting list for CBT. The waiting list time at the date of the Inquest remained 12 months The Inquest heard that there was insufficient capacity for the number of people referred for CBT which is why the waiting list had become so significant: It was unclear why the Iist had been allowed to increase to this level. The mechanisms for escalation between the commissioning body and the service provider did not appear to allow for early action to address the issue_
Report sections
Investigation and inquest
On 14th November 2017 | commenced an investigation into the death of John Paul Derwent; The investigation concluded on the 24th May 2018 and the conclusion was one of Suicide. The medical cause of death was 1a) Hanging: John Paul Derwent was on the waiting list for cognitive behavioural therapy. The target time for being seen was 6 weeks. At the time he was referred, the waiting time was 12 months He expressed suicidal ideation and was admitted as a voluntary patient to the Arden Ward. He found the environment exacerbated his agitation: He was discharged into the community on 8th November 2017 . The Home Treatment Team saw him on 1Oth and 11th November 2017. On 13th November 2017 he was found suspended ligature at his home address, 13 Stephens Road, Stalybridge.
Action should be taken
In my opinion, action should be taken to prevent future deaths and believe you have the power to take such action_
Similar PFD reports
Report details
- Reference
- 2018-0171
- Date of report
- 4 June 2018
- Coroner
- Alison Mutch
- Coroner area
- Manchester (South)
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: 2 Sep 2018 (estimated from the Judiciary.uk publication date).
Sent to
- Pennine NHS Trust
- Tameside and Glossop Clinical Commissioning Group