Source · Prevention of Future Deaths

Kyle Ashley Smith

Ref: 2014-0028 Date: 21 Jan 2014 Coroner: Jennifer Leeming Area: Manchester (West) Responses identified: 0 / 1 View PDF

An urgent mental health referral from a GP was significantly delayed in reaching the assessment team, with the reason for this critical communication failure remaining unknown and uninvestigated.

Date 21 Jan 2014
56-day deadline 18 Mar 2014 est.
Responses identified 0 of 1
Community health care and emergency services related deaths

Coroner's concerns

AI summary
An urgent mental health referral from a GP was significantly delayed in reaching the assessment team, with the reason for this critical communication failure remaining unknown and uninvestigated.
View full coroner's concerns
_ _ (1) Mr Smith's GP was concerned about his mental health when she saw him on the 15th of October 2013, to the degree that she decided to refer him urgently to Mental Health Assessment Team: (2) That referral did not reach the Team until the 18th of October.

(3) The reason for this has not been investigated and is not currently known. ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you andjor your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report; namely by 18th March 2014. I, the coroner, may extend the period, Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed; COPIES and PUBLICATTON I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Wife of the Kyle Ashley Smith.
2) Mr Simon Barber , Chief Executive, 5 Boroughs Partnership NHS Foundation Trust_Hollins Park House_Hollins Lane,Winwick Warrington_WA2 8WA delay ` the delay the delay

3) all of Longshoot Health Centre, Scholes, Wigan; Iam also under a to send the Chief Coroner a COpY of response: The Chief Coroner may publish either or both in a complete or redacted or summary form: He may send a copy of this report to any person who he believes may find it useful or of interest: You may make representations to me, coroner _ at the time of your response, about the release or the publication of your response by Chief Coroner. Dated Signed TFennulhg 21st January 2014 M Jennifer Leeming duty our the the

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Report details

Reference
2014-0028
Date of report
21 January 2014
Coroner
Jennifer Leeming
Coroner area
Manchester (West)

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: 18 Mar 2014 (estimated).

Sent to

Longshoot Health Centre

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