Sol Hadhasseh

_ read report received from Sols treating consultant psychiatrist at the Warwickshire & Coventry Partnership Trust: The consultant did not give evidence in person In his report consultant stated that he wrote to Sol's GP in Cromer on 14 November 2013 requesting that the GP refer Sol to the local Mental Health Trust: When giving evidence in person the GP confirmed that the letter was not received until December 2013, after Sol had died. It was not known that this was the case until the GP gave evidence before me at the Inquest The from the heard at the Inquest the Acting Deputy Service Manager of Norfolk & Suffolk NHS Foundation Trust's Access & Assessment Team_ In her evidence she stated that in her experience she would have expected the Warwickshire & Coventry Partnership Trust to have made a direct written referral Trust to Trust rather then via the GP_ given the complex needs and history of Sol and that this should have been planned in advance_ Whilst it can not be known whether had such referral been made the outcome for Sol would have been different; am nevertheless concerned that were similar circumstance to arise in the future then a preventable death might occur and there is continuing risk that other deaths could occur which could be avoided: was therefore concerned that procedures for transferring a patient to another Trust should be reviewed by the Warwickshire & Coventry Partnership Trust, This issue only arose in the light of the evidence given in person at the Inquest and was not apparent the statements and reports provided prior to the Inquest: would therefore record that it is accepted that in the circumstances which have arisen the Warwickshire & Coventry Partnership Trust "the Trust") have not had the opportunity to respond to that evidence_ Had the issue been apparent from statements and reports obtained then the Trust would have been asked to attend, therefore recognise that it is possible that steps may have already been taken to review the transfer of patients who are moving area In that event the response to this report will no doubt set out what steps have been taken