Recipients / Trafford Crisis Resolution and Home Treatment Team
Summary
Trends
Evidence
Reports, concerns and published responses Receiving a report does not make the recipient responsible for every concern in it. PFD Monitor does not verify whether stated actions happened.
Reports over time Reports naming this recipient by issue year.
* 2026 is projected from reports observed to 7 Sep 2026.
Reports 1 Naming this recipient
Published responses 0% Found for named reports
Concerns addressed 0 Across all linked responses
Stated actions 0 Described in responses
4 Sep 2013 Michael Stuart Irlam · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure to ensure a known next appointment at discharge from CRHTT View source Failure to ensure referral engagement without patient-initiated action View source
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Michael Stuart Irlam · 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
Michael Stuart Irlam was suffering from severe depression and anxiety and had been discharged from the CHRTT while awaiting further contact from IAPT. On 13 November 2012, he hung himself from the banister at his home. The principal concern was that vulnerable patients could experience a feeling of abandonment and deterioration while waiting without a confirmed appointment or clear information about the next stage of treatment.
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 Trafford Crisis Resolution and Home Treatment Team; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure a known next appointment at discharge from CRHTT
Wider context from the report “████████ Senior Clinical and Forensic Psychologist was engaged to conduct a Post Incident Review & Report.
That report concluded at page 31 - "Putting the patient first - perceived gaps from the patient perspective" that a waiting time of 24 days between discharge from CRHTT and the first appointment with IAPT could not be construed as a delay.
This issue arose at the Inquest hearing was the potential for a feeling of abandonment because of the discharge without any knowledge of how long it would be before the next contact ; of having to wait for the next stage/step without knowing when that would be. Mrs Irlam was clear that her husband deteriorated over this period despite the close, and loving, support provided by her and their family. That her husband found this a most distressing and difficult time.
Even if the General Panel do not consider a waiting time of 3 weeks plus to be a delay for someone with mental health issues I take the view that a waiting time of 2 weeks without knowing the next contact for help/treatment will be is not appropriate .
My concern is for the welfare of other patients who will fall into this gap between treatments/counselling who, unlike Mr Irlam, do not have a close and supportive family and the effect on them.
During the course of his evidence ████████ explained that the two organisations were working closer together administratively. He was not, however, able to respond to my line of enquiry as to why a patient could not be given an appointment with IAPT on discharge from CHRTT.
My concern is this. It seems to me most important and appropriate that a vulnerable patient with mental health issues ought not to be exposed to a feeling of abandonment , likely to lead to a deterioration in their condition, and that they should (where possible) be given an appointment with IAPT on discharge from CHRTT, if that is the agreed next step .
That would also deal with the issue that upon receipt of the awaited letter from IAPT the patient has to be proactive to engage the referral to IAPT.
(1) That if a follow-up with or referral to IAPT (or any other organisation) is deemed appropriate upon discharge from CRHTT then such an appointment should be arranged before or upon discharge.
(2)
(3)
” 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 Trafford Crisis Resolution and Home Treatment Team; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure referral engagement without patient-initiated action
Wider context from the report “████████ Senior Clinical and Forensic Psychologist was engaged to conduct a Post Incident Review & Report.
That report concluded at page 31 - "Putting the patient first - perceived gaps from the patient perspective" that a waiting time of 24 days between discharge from CRHTT and the first appointment with IAPT could not be construed as a delay.
This issue arose at the Inquest hearing was the potential for a feeling of abandonment because of the discharge without any knowledge of how long it would be before the next contact; of having to wait for the next stage/step without knowing when that would be. Mrs Irlam was clear that her husband deteriorated over this period despite the close, and loving, support provided by her and their family. That her husband found this a most distressing and difficult time.
Even if the General Panel do not consider a waiting time of 3 weeks plus to be a delay for someone with mental health issues I take the view that a waiting time of 2 weeks without knowing the next contact for help/treatment will be is not appropriate.
My concern is for the welfare of other patients who will fall into this gap between treatments/counselling who, unlike Mr Irlam, do not have a close and supportive family and the effect on them.
During the course of his evidence ████████ explained that the two organisations were working closer together administratively. He was not, however, able to respond to my line of enquiry as to why a patient could not be given an appointment with IAPT on discharge from CHRTT.
My concern is this. It seems to me most important and appropriate that a vulnerable patient with mental health issues ought not to be exposed to a feeling of abandonment, likely to lead to a deterioration in their condition, and that they should (where possible) be given an appointment with IAPT on discharge from CHRTT, if that is the agreed next step.
That would also deal with the issue that upon receipt of the awaited letter from IAPT the patient has to be proactive to engage the referral to IAPT .
(1) That if a follow-up with or referral to IAPT (or any other organisation) is deemed appropriate upon discharge from CRHTT then such an appointment should be arranged before or upon discharge.
(2)
(3)
” 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
Data last updated 7 September 2026