Terri Malone

I am Hugh Gregory Mark Bricknell, Senior Coroner for County of Herefordshire

On 9 February 2022 I commenced an investigation into the death of Terri Ann Malone. The investigation concluded at the end of the inquest on 10 October 2022. The conclusion of the inquest was ‘Alcohol Related.

The deceased was drinking excessively and probably died from ketoacidosis as a consequence of excessive alcohol consumption, however at the time of her death she was also known and had received assistance from Adult Safeguarding, Hereford Recovery Service, The Mental Health Crisis Team, the Police and others.

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. – [BRIEF SUMMARY OF MATTERS OF CONCERN) Initial contact with the service is with an inexperienced practitioner and a decision is made regarding a treatment plan without any direct contact being made by an experienced practitioner. Notwithstanding the above a service user is discharged from the service if they fail to attend an appointment and do not respond to a voicemail by the end of the day. This despite the patient being required to wait several months for an appointment. A decision is made to discharge the patient without establishing their current circumstances and the current (if any) input from other agencies; full details of whom and consent to share information could be obtained during initial instructions taken by a more experience practitioner.

In my opinion action should be taken to prevent future deaths and I believe you, [REDACTED], have the power to take such action.