Miles Abel
PFD Report
All Responded
Ref: 2016-wp25345
All 2 responses received
· Deadline: 26 Sep 2016
Coroner's Concerns (AI summary)
The procedure for GPs to refer patients to the Community Mental Health Team lacked an audit trail to confirm faxes were sent, and follow-up phone calls were not always made.
View full coroner's concerns
(1)The procedure in place at the time of Miles death where a GP from the surgery wished to refer a patient to the Community Mental Health Team was to fax the request but no audit trail was kept to show the fax had been sent.
(2) Although a telephone call was supposed to be made by the surgery to check that the fax had been received this was not always followed.
(3) Hence if for any reason the fax was not sent and the follow up telephone call was not made the Community Mental health Team would be unaware of the fact a patient had been referred to them. Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 | Fax 01722 332223
(2) Although a telephone call was supposed to be made by the surgery to check that the fax had been received this was not always followed.
(3) Hence if for any reason the fax was not sent and the follow up telephone call was not made the Community Mental health Team would be unaware of the fact a patient had been referred to them. Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 | Fax 01722 332223
Responses
Sent To
- Department of Health and Social Care
- Endless Street Surgery
Response Status
Linked responses
2 of 2
56-Day Deadline
26 Sep 2016
All responses received
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 15/01/2016 I commenced an investigation into the death of Miles Benedict Abel, 48. The investigation concluded at the end of the inquest on 07 July 2016. The conclusion of the inquest was suicide.
Circumstances of the Death
On the 14 January 2016 whilst at home at 1 Francis Villas Kingsland Road Salisbury Wiltshire Miles placed a ligature around his neck, attached the other end to a window which caused the injuries which led to his death.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.