Source · Prevention of Future Deaths
Georgina Lewis
Ref: 2016-0460
Date: 22 Dec 2016
Coroner: David Bowen
Area: Gwent
Responses identified: 0 / 1
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Concerns included the lack of family notification or consultation regarding discharge, absence of a discharge plan or follow-up support, and no contemporaneous GP notification. These failures left the patient without crucial support post-discharge.
Date
22 Dec 2016
56-day deadline
9 Apr 2017 est.
Responses identified
0 of 1
Coroner's concerns
Concerns included the lack of family notification or consultation regarding discharge, absence of a discharge plan or follow-up support, and no contemporaneous GP notification. These failures left the patient without crucial support post-discharge.
View full coroner's concerns
(1) The decision to discharge was made without notification to or consultation with any family member.
(2) Following the decision no discharge plan or follow up support was put in place.
(3) There was no contemporaneous notification to her GP of the discharge or the assessment leading to discharge, in fact the GP had still not received notification by the time of discovery of Mrs Lewis body
(2) Following the decision no discharge plan or follow up support was put in place.
(3) There was no contemporaneous notification to her GP of the discharge or the assessment leading to discharge, in fact the GP had still not received notification by the time of discovery of Mrs Lewis body
Report sections
Investigation and inquest
On 02/10/13 I commenced an investigation into the death of Mrs Georgina Lewis (d.o.b.08/11/55) The investigation concluded at the end of the inquest on 08/12/16. The conclusion of the inquest was Suicide as a result of hanging having recently been released from a psychiatric unit
Circumstances of the death
Mrs Lewis had been admitted to Talygarn Unit County Hospital Griffithstown on 20/09/13 as an informal patient following transfer from St Cadocs Hospital where she had been admitted following a S136 assessment, she was discharged from the unit 23/09/13 went missing from home on the 27/09/13 and was found dead in woods near home on 30/09/13
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Time frame and financial information for families
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Report details
- Reference
- 2016-0460
- Date of report
- 22 December 2016
- Coroner
- David Bowen
- Coroner area
- Gwent
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: 9 Apr 2017 (estimated).
Sent to
- Aneurin Bevan University Health Board