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InquestIQ

Imre Thomas

13 April 2021Coroner: Nicholas RheinbergArea: Lancashire and Blackburn with Darwen
Substance misuse interaction with psychiatric assessment and medical fitness determinationMedication errorsLocum doctor oversight and competency verification in Emergency Departments

Response Status

NHS England
NHS England
Overdue

Report Content

Coroner

5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – Cancelled hospital appointments putting vulnerable prisoners at risk. As the commissioning body you are asked to investigate the possibility of organising special prison clinics for visiting hospital consultants. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 1st June 2021. I, 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely the family of the deceased and the Greater Manchester NHS Trust. I have also sent it to the heads of Healthcare at HMP Garth and HMP Wymott who may find it useful or of interest. I am also under a duty to send the 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 your response by the Chief Coroner. 9 Dated 4th April 2021 SIGNED Nicholas Rheinberg Assistant Coroner

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