Mylon Sheppard
PFD Report
Historic (No Identified Response)
Ref: 2019-0025
Coroner's Concerns (AI summary)
Failures included ineffective oversight of duty worker decisions, poor waiting list management, unclear processes for patient non-attendance, and inadequate family involvement in care planning.
View full coroner's concerns
(1) Failure of any effective oversight of decisions made by duty workers (2) Failure to effectively manage waiting lists_ (3) Failure to have a clear process at the Hospital in respect of non attendance of patients (4) Failure to ensure that family members are including are care planning (where the patient is for that to happen).
(5) Failure to have a system in place that clearly identified GP boundaries and geographical boundaries in respect of local mental health services to minimise the risk of incorrect referrals to the wrong teams
(5) Failure to have a system in place that clearly identified GP boundaries and geographical boundaries in respect of local mental health services to minimise the risk of incorrect referrals to the wrong teams
Sent To
- Coventry & Warwickshire Partnership Trust
- Coventry NHS Trust
Response Status
Linked responses
0 of 2
56-Day Deadline
18 Jul 2019
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
5 October 2018 commenced an investigation into the death of Mylon Sheppard 49 vears old. The investigation concluded at the end of the inquest o 17 January 2019. conclusion of the inquest was suicide
Circumstances of the Death
Mr Sheppard hanged himself at his home and was found on 3 October 2018. He had significant contact with the Trust from 5 June 2018
Action Should Be Taken
In my opinion action should be_taken to prevent future deaths and believe YOu as Chief On The Day happy
Executive of the Trust have the power to take such action.
Executive of the Trust have the power to take such action.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.