Recurring concern

Delays in consultant review of patients

First to latest report 24 Sep 2013 — 27 Feb 2026

Reports that mention this concern
35
Times this concern has been raised
37
Stated actions linked to this concern
32

What this concern includes

Includes reports identifying delayed, missed or insufficiently timely consultant review of patients, including failures to seek or arrange an early consultant review where consultant input is required.

What is not included
  • Excludes delays in non-consultant consultations, referrals or specialist services unless the report specifically concerns consultant review.
  • Excludes failures involving only documentation, communication, continuity, staffing or on-call cover when delayed consultant review is not itself identified.
  • Excludes concerns about the quality or appropriateness of consultant decisions where timely review was not a material issue.

Reports and published responses 35 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Essex

    AI-generated summary

    David James FENN · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    David James FENN was admitted to hospital with suspected sepsis and septic left knee arthritis, after attending several days earlier with similar symptoms and being discharged home. He subsequently developed severe sepsis and multiorgan failure and died on 12 February 2025. The principal concerns were that sepsis was not appropriately recognised on 28 January, the Sepsis 6 pathway was not followed, timely consultant review was not obtained, and relevant clinical discussions and escalation did not occur adequately.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to seek an early Consultant Review

    Wider context from the report

    “2) An early Consultant Review was not sought. ”

    Source location

    David James FENN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement Epic as a unified electronic patient record providing real-time access to clinical information and an integrated communication and escalation platform.

    Verbatim wording from the response

    “Since October 2025, the Trust has implemented a new electronic patient record system, Epic. The Trust has consolidated a vast number of separate systems into one sole system that encompasses all the patient notes. This provides unified, one record per patient for all clinical and administrative data. The impact for patients is as follows:”

    Source location

    Response from East Sussex and North Essex NHS Foundation Trust
    Page 2 · response
    Published 18 March 2026

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing escalation and communication pathways are considered appropriate, including consultant review, alternative escalation, and waiting where patients remain stable.

    Verbatim wording from the response

    “A clinical governance presentation took place on 13 January 2026, wherein this matter was discussed at length. The Trust is satisfied that the methods of escalation and communications in place are appropriate and that patient safety remains a priority.”

    Source location

    Response from East Sussex and North Essex NHS Foundation Trust
    Page 3 · response
    Published 18 March 2026

    Open published response

  2. Manchester South

    AI-generated summary

    Margaret Crooks · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Margaret Crooks attended Stepping Hill Hospital after being diagnosed with a stroke and received intravenous thrombolysis. She developed a large bleed attributed to the thrombolysis, and died at Salford Royal Hospital on 20 February 2025. The report identified confusion about the level of overnight specialist stroke support and concern that time-critical treatment advice was not provided promptly or with stroke consultant input.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide timely stroke consultant input for thrombolysis complications

    Wider context from the report

    “The Inquest was told that Greater Manchester has a stroke network. In essence there are 3 hospitals that are stroke centres, and that Stepping Hill is one of them. However, under the system overnight (after 11.30pm) Salford Royal provides all expert stroke input into the other 2 centres. This is because the assessment of need has identified that the presence of stroke provision overnight at the other 2 centres is not justified by the demand. During the course of the inquest there appeared to be some confusion amongst some of the stroke clinicians who support the work as to the level of support that was to be provided by Salford Royal overnight to Stepping Hill. This creates a risk that expert and complex advice is not given as quickly as necessary. The evidence was that many of the decisions in relation to how to deal with complications arising from thrombolysis in a stroke patient need to be made by a stroke consultant and are time critical. In Mrs Crooks case the evidence of the stroke team was that they would have expected the overnight team based at Salford to have advised the Stepping Hill medical team to start giving treatment before the transfer to Salford Royal. The advice whilst Mrs Crooks was at Stepping Hill appears to have been given by the stroke Registrar at Salford rather than with input from the stroke consultant. In Mrs Cooks’ case it could not be confirmed that the outcome would have been different if she had received earlier treatment or there had been input earlier from a stroke consultant but in other cases a delay could change the outcome. ”

    Source location

    Margaret Crooks · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review the standard operating procedure governing out-of-hours specialist stroke advice.

    Verbatim wording from the response

    “• Reviewed the current Standard Operating Procedure (SOP) between CSCs and the other Greater Manchester stroke centres that details the protocol to be followed in terms of provision of hyper acute advice out of hours.”

    Source location

    Response from Greater Manchester Integrated Care
    Page 2 · response
    Published 18 November 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Agree amended wording defining specialist stroke advice in the standard operating procedure.

    Verbatim wording from the response

    “On review, it is evident that information for clinicians could be improved. In order to ensure complete clarity for clinicians involved in seeking and providing specialist advice in future, the network proposes adding further detail in the current SOP as to what constitutes specialist stroke advice. Discussions are underway to agree the amended wording which will be formally approved via the network’s governance. We anticipate this will be completed by the end of February 2026, when we will report again to you with updated information.”

    Source location

    Response from Greater Manchester Integrated Care
    Page 2 · response
    Published 18 November 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Obtain formal network governance approval for the amended standard operating procedure wording.

    Verbatim wording from the response

    “On review, it is evident that information for clinicians could be improved. In order to ensure complete clarity for clinicians involved in seeking and providing specialist advice in future, the network proposes adding further detail in the current SOP as to what constitutes specialist stroke advice. Discussions are underway to agree the amended wording which will be formally approved via the network’s governance. We anticipate this will be completed by the end of February 2026, when we will report again to you with updated information.”

    Source location

    Response from Greater Manchester Integrated Care
    Page 2 · response
    Published 18 November 2025

    Open published response

  3. Inner North London

    AI-generated summary

    Name not published · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    ████████ was detained under the Mental Health Act and admitted to psychiatric wards at the Tower Hamlets Centre for Mental Health before being found unresponsive in a patient room on 7 June 2022; her death was verified later that day. The jury identified several contributing factors, including a non-functioning door-locking system and shortcomings in patient observations. Further concerns included risk assessment, staff understanding and attitudes towards risk, auditing, and clinical oversight.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Delays in consultant review of patients

    Wider context from the report

    “8) Effective clinical oversight at THCMH There was clear evidence at the inquest that, following an extended bank holiday weekend period, there was a lack of consultant cover on Rosebank Ward and the male PICU ward, which led to one consultant attempting to cover both wards. This, in itself, is not the concern for the purposes of this report, but it puts the matter into some context. The consultant that was providing the cover to both wards gave evidence at the inquest, as did other senior nursing staff. The consultant’s own evidence raised questions about their own professional judgment in providing that cover to the wards and assessing the risks. The evidence of a senior nurse was that specific concerns had previously been raised about the consultant in question, including that consultant not being a “very responsive consultant” and there having been “a pattern” with this consultant not reviewing patients in a timely manner. The court was told that those concerns had previously been raised with the Trust’s Clinical Director and Associate Clinical Director and, despite this, no discernible change had been noted. The Trust’s response to this during the inquest was to say that the consultant in question no longer works for the Trust and therefore the risk has been addressed. In my opinion, this is a misunderstanding of the risk. I consider that the risk is that senior nursing staff raised a serious issue with very senior (director level) clinicians about a pattern of issues creating risk to patients (some relating to other patient deaths and / or other serious untoward incidents) and little, if any, evidence was provided about how the Trust dealt with this serious issue from a clinical governance and oversight point of view. As such, the concern remains. ”

    Source location

    Name not published · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

  4. Essex

    AI-generated summary

    LAURA-JANE KIRSTEN NICOLE SEAMAN · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Laura-Jane Seaman died at Broomfield Hospital on 23 December 2022 following a massive intra-abdominal haemorrhage after a recent vaginal delivery, with subsequent disseminated intravascular coagulation. The principal concerns were failures to recognise and escalate maternal collapse and hypovolaemia, obtain and record vital signs and blood-test results, examine for covert bleeding, activate the major haemorrhage protocol, and provide appropriate senior review. The inquest concluded that her death was avoidable and contributed to by neglect.

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    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to obtain consultant obstetric input, medical review and imaging before therapeutic anticoagulation

    Wider context from the report

    “(11) Therapeutic anticoagulation was administered without consultant obstetric input, further medical review or imaging where there had been hours of deranged vital signs that were inconsistent potential complications for pulmonary embolism. ”

    Source location

    LAURA-JANE KIRSTEN NICOLE SEAMAN · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide guidance on reducing venous thromboembolism risk during pregnancy and the puerperium, including anticoagulation decisions when bleeding risk exists.

    Verbatim wording from the response

    “3. Reducing the Risk of Venous Thromboembolism during Pregnancy and the Puerperium⁶ (Green-top Guideline No. 37a April 2015) states that: “Low molecular weight heparin (LMWH) should be avoided, discontinued or postponed in women at risk of bleeding after careful consideration of the balance of risks of bleeding and thrombosis.””

    Source location

    Response from Royal College of Obstetricians and Gynaecologists
    Page 4 · response
    Published 18 December 2024

    Open published response

  5. South Yorkshire (Western)

    AI-generated summary

    Bryan Andrews and Mary Andrews · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Bryan and Mary Andrews died at their home on 27 November 2022 from multiple stab wounds inflicted by their adult son. The principal concern was a lack of communication between services about the relationship between his epilepsy and psychotic symptoms, resulting in treatment delays, rejected referrals and failures to share important information.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to carry out consultant review of antipsychotic medication alongside epilepsy medication

    Wider context from the report

    “There was a lack of communication between services about the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths. This led to significant time lapses in treatment and rejection of referrals, most notably: i. On 18 November 2020 an urgent referral was made to the Single Point of Access Team by his General Practitioner, concerned about his prolonged suicidal ideation. He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the Improving Access to Psychological Therapies Service. ii. On 20 November 2020 his General Practitioner referred him to the Single Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines. iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the Improving Access to Psychological Therapies Service offered work on living with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a request to the General Practitioner for the mental health nurse in the surgery to offer an assessment was appropriate. The surgery were not informed of this. iv. On 16 December 2020 the Single Point of Access Team received a referral from a consultant neurologist requesting a medication review as his anxiety levels were affecting his epilepsy treatment. It was felt at that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist. v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the emergency department. Once there he was assessed by the Liaison Psychiatry Team. He was referred to the Home Treatment Team, but his consultant neurologist was not informed. vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic medication with his epilepsy medication was not carried out. vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team. viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was unclear whether a new treatment episode had been opened. ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner. x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral. The referral was triaged on 22 November 2022 when he was invited to contact the Single Point of Access Team for a further discussion. ”

    Source location

    Bryan Andrews and Mary Andrews · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Essex

    AI-generated summary

    Ernest Smith · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Ernest Smith died in hospital from sepsis associated with hospital-acquired pneumonia and an infected haematoma, which developed after prophylactic anticoagulation. Concerns included delays in medical and consultant reviews, delayed antibiotics for the infected haematoma, and failure to follow the Sepsis Protocol.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Delays in consultant review

    Wider context from the report

    “a. Medical review requested on 10 March by nurses due to concerns about the acute development of bilateral bruising on Mr Smith's legs. This request was chased by nurses on 11 March and was not conducted until the evening of 12 March. b. A further medical review was conducted in the early hours of 13 March as Mr Smith was in pain and had developed a leg haematoma. c. It took 3 days for consultant review of Mr Smith. On 13 March Mr Smith was reviewed by a consultant from another ward and prophylactic anticoagulation was discontinued. ”

    Source location

    Ernest Smith · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. North London

    AI-generated summary

    Peter Carr · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Peter Carr developed a severe rash and was admitted to North Middlesex Hospital, where he was later found to have a drug reaction consistent with Stevens-Johnson Syndrome. The principal concern was that patients with acute, severe skin conditions may not receive consultant dermatology input, timely biopsy, and ongoing dermatological oversight during an inpatient stay.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of consultant dermatology input within 24 hours for acute severe skin conditions

    Wider context from the report

    “That patients who contact medical services with acute, severe, skin conditions as primary presentations, or as a component of a complex presentation, may not have consultant dermatology input and biopsy within 24 hours and ongoing consultant dermatology oversight for the duration of an inpatient stay. ”

    Source location

    Peter Carr · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Birmingham and Solihull

    AI-generated summary

    Hilary THOMAS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Hilary THOMAS attended hospital with abdominal pain on 28 and 29 October 2022, then reattended on 30 October in a shocked and profoundly unwell state. She underwent emergency surgery for ischaemic bowel caused by adhesions but died on 31 October 2022. The principal concerns were delayed review of blood test results, failure to escalate her case for consultant review, and delay in arranging a CT scan.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to escalate eligible emergency department patients for consultant review

    Wider context from the report

    “2. Mrs Thomas reattended hospital with severe pain, was over age 70 and an unscheduled return within 72 hours. The Doctor should have considered and followed national guidance from the Royal College of Emergency medicine published in June 2016 (consultant sign off) which confirmed Mrs Thomas should have been reviewed by a consultant. Mrs Thomas was not escalated for consultant review. There was no evidence at the inquest that this guidance has been adopted by the Trust nor that staff are aware of it and have been trained on it. ”

    Source location

    Hilary THOMAS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement a policy empowering any multiprofessional team member to escalate delayed assessment or transfer to the consultant on call.

    Verbatim wording from the response

    “The Trust has therefore implemented a new policy developed by the Clinical Service Leads for EGS and ED, alongside a programme of education (from August 2023) in which any member of the multi-professional team are invited to escalate concerns regarding delayed assessment, or delayed transfer of patients to SAU, to the consultant on call. This will be enhanced by a communication strategy that will include direct teaching and laminated posters displayed in acute surgical areas at all acute sites (by 31 October 2023). This communication will emphasise the importance of this action for patient safety and will not be a punitive action.”

    Source location

    Response University Hospitals Birmingham NHS Foundation Trust
    Page 3 · response
    Published 7 July 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Deliver an education programme on escalation for delayed assessment or transfer from August 2023.

    Verbatim wording from the response

    “The Trust has therefore implemented a new policy developed by the Clinical Service Leads for EGS and ED, alongside a programme of education (from August 2023) in which any member of the multi-professional team are invited to escalate concerns regarding delayed assessment, or delayed transfer of patients to SAU, to the consultant on call. This will be enhanced by a communication strategy that will include direct teaching and laminated posters displayed in acute surgical areas at all acute sites (by 31 October 2023). This communication will emphasise the importance of this action for patient safety and will not be a punitive action.”

    Source location

    Response University Hospitals Birmingham NHS Foundation Trust
    Page 3 · response
    Published 7 July 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Deliver direct teaching and display laminated posters in acute surgical areas at all acute sites by 31 October 2023.

    Verbatim wording from the response

    “The Trust has therefore implemented a new policy developed by the Clinical Service Leads for EGS and ED, alongside a programme of education (from August 2023) in which any member of the multi-professional team are invited to escalate concerns regarding delayed assessment, or delayed transfer of patients to SAU, to the consultant on call. This will be enhanced by a communication strategy that will include direct teaching and laminated posters displayed in acute surgical areas at all acute sites (by 31 October 2023). This communication will emphasise the importance of this action for patient safety and will not be a punitive action.”

    Source location

    Response University Hospitals Birmingham NHS Foundation Trust
    Page 3 · response
    Published 7 July 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Responsibility for addressing emergency department patient volume rests with the Department of Health and Social Care.

    Verbatim wording from the response

    “This area of concern is for the Department of Health and Social Care however we acknowledge that there has been a significant increase in demand for assessment by the Emergency General Surgery (EGS) Service at UHB. This was the service to which Mrs Thomas was appropriately referred by the Emergency Department. In this case failure of assessment and escalation occurred after this referral. She was seen by the EGS service at 11:30am by an experienced Specialist Registrar (SpR) who was in the 7th Year of specialist training (ST7). When that SpR returned at 20:00 Mrs Thomas, after waiting for so long, had taken her own discharge. We acknowledge that Mrs Thomas had to wait far too long and that this was a failure of the EGS service.”

    Source location

    Response University Hospitals Birmingham NHS Foundation Trust
    Page 2 · response
    Published 7 July 2023

    Open published response

  9. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    Roy WALKLET · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Roy Walklet died at Royal Stoke University Hospital on 9 April 2022 from multiorgan failure caused by a massive gastroduodenal haemorrhage, contributed to by ibuprofen, after multiple large bleeds from a duodenal ulcer. Concerns included delays in performing a gastroscopy because a hospital bed had not been allocated, and a failure to ensure that the consultant gastroenterologist reviewed him during the morning ward round after he was allocated to the consultant’s patient list.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure consultant awareness and timely review of allocated patients remaining in Accident and Emergency

    Wider context from the report

    “I was further told during the inquest that Mr Walklet was allocated a bed in the Hospital either late on 7th April 2022 or early on 8th April 2022 and that his care was allocated to a consultant gastroenterologist ███████ who should have seen Mr Walklet during his morning ward round but did not do so. ███████ told me that he was not aware that Mr Walklet had been allocated to his list of patients. Mr Walklet’s family believe that this error occurred because, whilst Mr Walklet had been allocated a bed on the ward, he actually remained in the Accident and Emergency department. As a result, Mr Walklet’s condition and care was not reviewed by the consultant gastroenterologist until later that day. At the time Mr Walklet was still suffering from a bleeding duodenal ulcer from which he was to die later the same day. ”

    Source location

    Roy WALKLET · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. North Northumberland and South Northumberland

    AI-generated summary

    Odessa Carey · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Odessa Carey was last seen alive at her home on 4 April 2019 and was found dead on 7 April 2019; the inquest recorded the conclusion “Unlawfully killed”. The report raised concerns about multi-agency risk assessment, substance-misuse referrals, discharge and care coordination, risk assessment, record keeping, and delays in referral to the Community Treatment Team.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide Consultant Psychiatrist review after 30 May 2018

    Wider context from the report

    “4. Discharge from the Community Treatment Team on 6 August 2018 There was no pre-discharge meeting in line with trust CPA Policy involving the family, lead professionals, other agencies or a Consultant Psychiatrist for future planning. A more assertive approach to engagement may have been appropriate. I am concerned that following discharge from the Lowry ward to the community and prior to discharge from the community treatment team, the deceased was seen only four times in person by individuals from the mental health team and only once by the care coordinator. I am concerned that more intense, in person engagement was warranted and discharge from the Community Treatment Team was premature. I am concerned that the service user was not seen by a Consultant Psychiatrist at all after 30 May 2018 despite enquiring about a further appointment. ”

    Source location

    Odessa Carey · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026