Ia)

: In the circumstances it is my statutory to report to you: _ The inquest heard that his family were supportive and had attended MDT meetings whilst he was an in-patient: Following his discharge there was no attempt t0 engage his family and obtain information from them or work with them to support him in the community. There was no clear policy about how a family could be effectively engaged by the CMHT; The inquest heard that he was treated as an in-patient by the Pennine Care team within Stockport MBC. His consultant whilst he was an in-patient was part of the Stockport Team If he had been a Stockport Resident he would have been discharged under the care of that consultant in the community and had a follow up appointment booked with that Doctor at discharge. However because he was Tameside Resident at discharge his care moved to the Tameside Borough Pennine Care Team: That meant he had to be allocated to a community psychiatrist based there. That did not happen and no follow up appointment was made; The inquest heard that it was recognised as part of his discharge planning that there should be regular contact in the community with the CMHT That did not happen and there was no escalation or discussion about the picture of very limited contact as it evolved post discharge. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you have the power to take such action YOUR RESPONSE You are under a duty to respond t0 this report within 56 days of the date of this report; namely by 7th February 2020. |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely Mr Marsland's parents, who may find it useful or of interest: am also under a duty to send Chief Coroner a copy of your response The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest You may make representations to me; the coroner, at the time of your response_about the release or the publication of duty - very the your response by the Chief Coroner_ Alison Mutch OBE HM Senior Coroner 13.12.2019 AkO