Recurring concern

Unreliable community care-coordinator provision and contact

First to latest report 30 Jan 2013 — 25 Sep 2023

Reports that mention this concern
5
Times this concern has been raised
5
Stated actions linked to this concern
4

What this concern includes

Includes failures in the dedicated community care-coordinator function, including failure to appoint or maintain a coordinator, inadequate workload or cover, unclear coordination responsibility, absent guidance on contact frequency, and insufficient contact or follow-up where the coordinator is responsible for monitoring care and risk.

What is not included
  • Excludes generic multi-agency communication or care-coordination failures where no community care-coordinator function or equivalent designated coordination responsibility is identified.
  • Excludes clinical treatment, care-package provision and social-worker access failures where the care-coordinator function is not the deficient control.
  • Excludes mental-health-specific care coordination when the assertion belongs to a separately named mental-health pathway or coordinator system.
  • Excludes generic staffing or workload deficiencies unless they directly impair provision, continuity or contact by a community care coordinator.

Reports and published responses 5 reports

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

  1. Manchester West

    AI-generated summary

    Robert Leigh · 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

    Robert Leigh was found dead at home on 7 February 2022, having suspended himself by a ligature attached to a loft beam. The report identifies missed mental-health appointments, a lack of interim cover and a lack of resilience arrangements during the absence of his Care Coordinator as substantive concerns.

    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 appoint interim Care Coordinator or Community Psychiatric Nurse cover

    Wider context from the report

    “1. During the Inquest evidence was heard that: - i. During the period from the 25th of October 2022 to the 4th of January 2023 there were no visits from a Care Coordinator, or a Community Psychiatric Nurse, and all the 2-week planned visits did not take place, so that 4 or 5 visits were missed. ii. There was no appointment of an interim Care Coordinator or a Community Psychiatric Nurse to cover the 2 weekly planned appointments following the absence of YL. iii. There was no responsibility on a Duty officer to review planned appointments during the absence of a Care Coordinator and to arrange for a Community Psychiatric Nurse to attend any planned appointments. iv. There were no resilience plans in place to cover the absence of a Care Coordinator, either in relation to short term or long-term absences. ”

    Source location

    Robert Leigh · Prevention of Future Deaths report
    Page 3 · 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 Care Coordinator handover sheet for planned absences, identifying required follow-up and accountable staff.

    Verbatim wording from the response

    “Following Mr Leigh’s inquest, the team has now implemented a handover sheet, which is completed by the Care Coordinator prior to any planned absence, such as annual leave or a planned medical intervention. This ensures the Care Coordinator has considered any follow up for service users that is required during their period of absence and identifies who will carry out any planned interventions such as administration of depot medications, undertaking face to face visits, and making telephone contacts. If specific follow up is not required during the period of planned absence, the service user, and their families or carers will be provided with the contact details for the team, should they require additional support. The Team Manager or Senior Practitioner have oversight and hold responsibility to ensure any actions required are undertaken by the team.”

    Source location

    Response from Greater Manchester Mental Health NHS Foundation Trust
    Page 2 · response
    Published 28 November 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

    Establish manager-led review and coverage arrangements for unplanned, short-term and long-term Care Coordinator absences, including prioritised visits, duty-officer follow-up and caseload reallocation.

    Verbatim wording from the response

    “For unplanned absences such as sickness, it is expected that the Care Coordinator, at the point of contacting the Team Manager or Senior Practitioner to advise of their absence, will provide a detailed handover of any work that is required to be covered.”

    Source location

    Response from Greater Manchester Mental Health NHS Foundation Trust
    Page 2 · response
    Published 28 November 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

    Update the Older Adult Community Mental Health Team Standard Operating Procedure to reflect the absence-cover arrangements.

    Verbatim wording from the response

    “The Service Manager will ensure that the Older Adult Community Mental Health Team Standard Operating Procedure is updated to reflect these changes by the end November 2023. The Operational Manager will undertake an audit in three months’ time to ensure the process outlined in this response is embedded and being adhered to.”

    Source location

    Response from Greater Manchester Mental Health NHS Foundation Trust
    Page 3 · response
    Published 28 November 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

    Audit the absence-cover process after three months to verify that it is embedded and being followed.

    Verbatim wording from the response

    “The Service Manager will ensure that the Older Adult Community Mental Health Team Standard Operating Procedure is updated to reflect these changes by the end November 2023. The Operational Manager will undertake an audit in three months’ time to ensure the process outlined in this response is embedded and being adhered to.”

    Source location

    Response from Greater Manchester Mental Health NHS Foundation Trust
    Page 3 · response
    Published 28 November 2023

    Open published response

  2. Black Country

    AI-generated summary

    Ms Shannon Quinn · 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

    Ms Shannon Quinn, a 24-year-old woman with a complex mental health history and repeated self-harm, was found hanging in her room at Oak House on 9 January 2019 and was pronounced deceased shortly afterwards. The report identified concerns including inadequate information sharing and joint care planning, insufficient staff training, escalating ligature risk without sufficient environmental measures, and failure to adhere to five-minute observations.

    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

    Insufficient contact with the care coordinator

    Wider context from the report

    “3. There was a lack of a joint multi-disciplinary/Trust care plan and insufficient contact with the care coordinator due to difficulties in travelling to meet the patient outside the normal Trust area and staff sickness absence. ”

    Source location

    Ms Shannon Quinn · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Plymouth, Torbay and South Devon

    AI-generated summary

    Martin Glyn Baker · 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

    Martin Glyn Baker, who had longstanding mental health difficulties and a history of suicide attempts, died following a prescription drug-related death. The inquest identified concerns about inadequate communication with his family, a shortage of care coordinators, and a risk assessment that did not address his periodic impulsivity.

    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

    Shortage of care coordinators

    Wider context from the report

    “(2) It was also accepted in evidence that at the time of these events there was a shortage of care coordinators something described as “very far from ideal.” I was advised that this situation has now been corrected. Nevertheless, it was the clear view of the family, which I accepted, that in the absence both of a care coordinator and the involvement of the family there had been no one to act as an advocate on Mr Baker’s behalf, something that had been to his detriment. ”

    Source location

    Martin Glyn Baker · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. Nottinghamshire

    AI-generated summary

    Rohid SHERGILL · 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

    Rohid Shergill, who had Duchenne’s muscular dystrophy and was fed through a nasogastric tube, died on 14 March 2016 after the tube was inserted into his lung and was used for feeding and medication. The principal concerns included inadequate checking of the tube position, uncertainty about parental understanding of pH testing, insufficient information-sharing between trusts, unclear care coordination, and possible contamination from repeated syringe use.

    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 clear allocation of a named keyworker or lead nurse for community care coordination

    Wider context from the report

    “3. Clear guidance on a named keyworker / lead nurse who is responsible for coordinating the care of children cared for in the community. ”

    Source location

    Rohid SHERGILL · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Manchester South

    AI-generated summary

    Gareth Mark Slater · 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

    Gareth Mark Slater, who had a history of bipolar affective disorder and had been discharged from hospital into his own accommodation, was found in the River Medlock on 31 March 2013 after apparently falling from Bardsley Bridge. The Inquest concluded that he died from drowning and multiple injuries, with bipolar affective disorder recorded as a contributing condition, and found no evidence of an intention to end his life. Concerns included inadequate discharge planning, lack of a care plan and follow-up arrangements, insufficient assessment of his ability to live independently, and poor preparation of his accommodation.

    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 guidance on frequency of community contact

    Wider context from the report

    “10. The lack of a structured and considered Care Plan meant that the only person having any contact with Gareth in the Community was his Care Co-Ordinator who had only been involved with Gareth since the 8th October 2012. There was no guidance to his Care Co-Ordinator as to how often should be seen. ”

    Source location

    Gareth Mark Slater · Prevention of Future Deaths report
    Page 2 · 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