Nadine Thurman

PFD Report Historic (No Identified Response) Ref: 2014-0303
Date of Report 31 July 2014
Coroner Robin Balmain
Coroner Area Black Country
Response Deadline est. 25 September 2014
Coroner's Concerns (AI summary)
The psychiatric assessment was flawed due to a relative being excluded and the patient being inappropriately prompted about solitary assessment.
View full coroner's concerns
My concerns relate to the psychiatric assessment of Mrs Thurman gave evidence to me that he was not allowed to contribute to the assessment: was told that Mrs. Thurman was asked by a nurse if she was content to be seen on her own. That seems to me to be an approach that is suggestive of the answer and is This Office is open Monday to Thursday 8am to 4pm. Friday 8am to 3pm hung again
Sent To
  • Dudley and Walsall NHS Mental Health Trust
Response Status
Linked responses 0 of 1
56-Day Deadline 25 Sep 2014
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
This investigation was commenced on 12th November 2012 and concluded on 23rd June 2014. A conclusion was reached that the deceased herself whilst suffering from an anxiety related disorder.
Circumstances of the Death
There was a history of paracetamol and vodka misuse on 19uh October 2012 following treatment she was seen by the crisis team: On 28th October 2012 there was a further misuse of paracetamol and hospital treatment and seen by the crisis team: On 5th November 2012 Mrs. Thurman was found hanging at home:
Related Inquiry Recommendations

Public inquiry recommendations addressing similar themes

Improve perinatal mortality recording
Morecambe Bay Investigation
Flawed mortality reviews
Implement medical examiner system
Morecambe Bay Investigation
Flawed mortality reviews
Extend medical examiners to stillbirths
Morecambe Bay Investigation
Flawed mortality reviews
Transparency use and sharing of information
Mid Staffs Inquiry
Flawed mortality reviews
Independent medical examiners
Mid Staffs Inquiry
Flawed mortality reviews
Independent medical examiners
Mid Staffs Inquiry
Flawed mortality reviews
Death certification
Mid Staffs Inquiry
Flawed mortality reviews
Death certification
Mid Staffs Inquiry
Flawed mortality reviews
Death certification
Mid Staffs Inquiry
Flawed mortality reviews

Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.