UK Inquiry Tracker

REDACTED

PFD Report Historic (No Identified Response) Ref: 2022-0095

Date of Report 28 March 2022

Coroner Sean McGovern

Coroner Area Warwickshire

Response Deadline est. 23 May 2022

Mental Health related deaths Suicide (from 2015)

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

Concerns include the failure to appoint a Care Co-ordinator and significant, ongoing staffing shortages within mental health services in the North Warwickshire area.

View full coroner's concerns

During the inquest, the evidence and information revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. i. I am concerned that the failure to appoint a Care Co-ordinator may have contributed to death.

ii. I am concerned that there remain significant staffing shortages in the North Warwickshire area. I heard evidence that staffing was 65% below recommended levels as of March 2022.

Part of a Series

9 separate reports were issued from this inquest, each sent to different organisations.

2019-0397
Sent to: College of Policing;

No responses yet
2020-0061
Sent to: Department of Health and Social Care; NHS England;

All responded
2022-0036
Sent to: Broadgate General Practice; General Medical Council;

1 of 2 responded
2023-0115
Sent to: Children’s Commissioner for England; Department for Education; Department of Health and Social Care;

No responses yet
2024-0031
Sent to: London Fire Brigade;

All responded
2025-0045
Sent to: Unite Group plc;

All responded
2025-0314
Sent to: 49 Marine Avenue Surgery; Department of Health and Social Care; Moorbridge School; North East and North Cumbria Integrated Care Board; Northumbria Healthcare NHS Foundation Trust;

All responded
None
Sent to: Domestic Abuse Management Board Surrey PoliceSurrey County Council

1 of 2 responded

This report (2022-0095) is shown above.

Sent To

Coventry and Warwickshire Partnership NHS Trust

Response Status

Linked responses 0 of 1

56-Day Deadline 23 May 2022

About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections

Investigation and Inquest

On 13th August 2021, I commenced an investigation into the death of (aged 42 years). The investigation concluded at the end the inquest on 28th March 2022 at Warwickshire Coroners Court.

Circumstances of the Death

was found hanging on 25 July 2021 at his home address . On 2nd May 2021, he presented at University Hospital Coventry & Warwickshire with suicidal ideation. He was seen by a Community Mental health Nurse on 4th May 2021. From the 5th May to 20th May 2021 he was given a crisis bed at Harry Salt House. He returned home and was seen regularly by the Crisis Team. On 19th June he was transferred to Community Mental Health Team. He was on a waiting list for a Care Co-ordinator but a Care -Ordinator was not appointed before he died. On 9th July 2021, raised her concerns that a Care Co-ordinator had not been appointed. On 23rd July 2021, telephoned the Mental Health Team in a very distressed state asking why the waiting list is so long and explained that he didn’t have anyone in the Mental Health Team to talk to. He was explained to him that he could go to A&E or call the Samaritans if he felt unsafe.