William Grieve

I am Emma Serrano, Area Coroner, for the coroner area of Staffordshire.

On the 28 th August 2024, I commenced an investigation into the death of Mr William Anthony Grieve.  The investigation concluded at the end of the inquest on 17 March 2024. The conclusion of the inquest was a short for conclusion of suicide. The cause of death was: 1a  Hanging

Mr Grieve was found deceased, on the 20 August 2024, at his home address [REDACTED].

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.  –

1. Evidence emerged during the inquest that Mr Grieve was under the care of Stoke Talking Therapies, and had also presented at the Stoke crisis Evolution Team. Both had conducted suicide risk assessments of Mr Grieve.
2. Both assessments, were incorrect, and took account of incorrect information because neither team had access to the others computer system.  Stoke Talking Therapies used IAPTUS and Crisis resolution used Lorenzo.  There was no way for either team to see the others electronic notes.
3. It was said in evidence, that a member of staff had not carried out a risk assessment properly whoever, nothing had been done to address this and there were no plans to address this.  The concern being that staff training needs are not being addressed.

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