15 Oct 2021 Darren John Lawrence · Prevention of Future Deaths report Manchester City
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Concerns raised 12 Failure of SUI investigation to obtain evidence from an important witness View source Lack of a procedure for regular monitoring of medication prescribing, collection and response View source Failure to use alternative methods to obtain direct contact after unsuccessful phone calls View source Inadequate GP system for recording and reviewing correspondence View source Inadequate transfer, communication and follow-up from HBTT to CMHT View source Lack of escalation and contact process with secondary care when requested medication is not prescribed or contact fails View source Failure to identify significant investigative omissions during investigation oversight View source Failure to consider referral back to HBTT when circumstances change View source Failure to ensure prescribed medication for a patient with serious mental health problems View source Lack of planned CMHT/HBTT involvement with the GP in overall management and treatment View source Inadequate communication with and from the Pharmacy team View source Lack of escalation following disengagement from community services View source See 9 more concerns
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Darren John Lawrence · 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
Darren John Lawrence had a history of suicidal thoughts, plans, previous attempts, mental ill health, disengagement from services and medication noncompliance. He was found dead at his home on 29 August 2020, and the inquest conclusion was suicide. Principal concerns included inadequate communication and follow-up between mental health services and the GP practice, failure to ensure that prescribed venlafaxine was issued and collected, insufficient escalation when direct contact with him was unsuccessful, and inadequate systems for managing correspondence and medication.
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. The report was sent to Droylsden Road Family Practice; that does not assign responsibility.
PFD Monitor interpretation Failure of SUI investigation to obtain evidence from an important witness
Wider context from the report “h. The CMHT Responsible Clinician was an important witness but the GMMH SUI investigation did not obtain a statement from him and those carrying out the investigation failed to recognise the significance of this. Nor was this identified in the overview of the report before it was signed off. This meant all the lessons for future care and planning were not learnt. The court has received evidence about the same issue in other inquests involving deaths of GMMH patients and is a repeated matter of concern
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Droylsden Road Family Practice; that does not assign responsibility.
PFD Monitor interpretation Lack of a procedure for regular monitoring of medication prescribing, collection and response
Wider context from the report “d. There was no GMMH procedure or process to check regularly if the deceased was being prescribed the correct medication and it being collected. In addition his response to it.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Droylsden Road Family Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to use alternative methods to obtain direct contact after unsuccessful phone calls
Wider context from the report “b. There was lack of appropriate escalation following the deceased’s disengagement with community services in 2019 but also in 2020 when there was a repeated lack of direct contact with him as well as the recognition of its importance. From June 2020 no other methods were tried to have direct contact with the deceased apart from attempts from phone calls which were repeatedly unsuccessful .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Droylsden Road Family Practice; that does not assign responsibility.
PFD Monitor interpretation Inadequate GP system for recording and reviewing correspondence
Wider context from the report “f. The GP system for recording receipt of correspondence and ensuring that they were seen and reviewed by a GP was inadequate . As was communication with and from the Pharmacy team. Nor was there consideration of a system or process for contacting the secondary care provider GMMH in such circumstances when medication was not prescribed as requested and no contact could be made with the deceased. There was no escalation process/procedure.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Droylsden Road Family Practice; that does not assign responsibility.
PFD Monitor interpretation Inadequate transfer, communication and follow-up from HBTT to CMHT
Wider context from the report “a.The transfer and communication process from the HBTT to the CMHT in 2019 and 2020 was unsatisfactory with inadequate follow up as required . The court has received evidence about similar problems in other inquests in which GMMH was the treating NHS Trust and is a repeated issue of concern.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Droylsden Road Family Practice; that does not assign responsibility.
PFD Monitor interpretation Lack of escalation and contact process with secondary care when requested medication is not prescribed or contact fails
Wider context from the report “f. The GP system for recording receipt of correspondence and ensuring that they were seen and reviewed by a GP was inadequate. As was communication with and from the Pharmacy team. Nor was there consideration of a system or process for contacting the secondary care provider GMMH in such circumstances when medication was not prescribed as requested and no contact could be made with the deceased. There was no escalation process/procedure .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Droylsden Road Family Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to identify significant investigative omissions during investigation oversight
Wider context from the report “h. The CMHT Responsible Clinician was an important witness but the GMMH SUI investigation did not obtain a statement from him and those carrying out the investigation failed to recognise the significance of this. Nor was this identified in the overview of the report before it was signed off . This meant all the lessons for future care and planning were not learnt. The court has received evidence about the same issue in other inquests involving deaths of GMMH patients and is a repeated matter of concern
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Droylsden Road Family Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to consider referral back to HBTT when circumstances change
Wider context from the report “c. There was no consideration of referral back to the HBTT by the CMHT when the deceased may have benefited from it when circumstances changed . There was disengagement from services after the end of February 2020 as well as evidence of noncompliance with medication.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Droylsden Road Family Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure prescribed medication for a patient with serious mental health problems
Wider context from the report “e. The GP practice failed to ensure that medication (for a patient with a serious mental health problem with a history of suicidal ideas, plans and previous attempts) was prescribed . This is despite them receiving letters from GMMH clinicians requesting this. Consequently, the deceased did not receive the therapeutic benefit the medication would have provided.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Droylsden Road Family Practice; that does not assign responsibility.
PFD Monitor interpretation Lack of planned CMHT/HBTT involvement with the GP in overall management and treatment
Wider context from the report “g. There was no CMHT/HBTT planned involvement with the GP in the overall management and treatment of the deceased apart from simply requesting that they issue repeat prescriptions . This meant that opportunities to develop other lines of communication and information sharing as well as support were lost.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Droylsden Road Family Practice; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication with and from the Pharmacy team
Wider context from the report “f. The GP system for recording receipt of correspondence and ensuring that they were seen and reviewed by a GP was inadequate. As was communication with and from the Pharmacy team . Nor was there consideration of a system or process for contacting the secondary care provider GMMH in such circumstances when medication was not prescribed as requested and no contact could be made with the deceased. There was no escalation process/procedure.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Droylsden Road Family Practice; that does not assign responsibility.
PFD Monitor interpretation Lack of escalation following disengagement from community services
Wider context from the report “b. There was lack of appropriate escalation following the deceased’s disengagement with community services in 2019 but also in 2020 when there was a repeated lack of direct contact with him as well as the recognition of its importance. From June 2020 no other methods were tried to have direct contact with the deceased apart from attempts from phone calls which were repeatedly unsuccessful.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations