Inquest into the Death of Anthony Ian EDWARDS

Contributing factors

• Inadequate individual management plans
• Inadequate risk management plans
• Inadequate discharge planning
• Failure to contact family/carers regarding discharge
• Failure to involve carers in treatment decisions
• Lack of adequate psychiatric assessment before discharge
• Delayed psychiatric response to suicidal disclosures
• Insufficient follow-up after discharge
• Inadequate longitudinal risk assessment procedures
• Fragmented service delivery (CERT not integrated with ongoing care)
• Inadequate security measures for involuntary patients
• Inadequate communication with families
• Staff shortages and time constraints
• Understaffing requiring inexperienced registrars to make critical decisions alone
• Inadequate policies for carer involvement

Coroner's recommendations

1. Develop policies and procedures for Carer's Plans addressing patient diagnosis, medication, relapse prevention, warning signs, and carer support services
2. Continue funding and resources to progress Stokes Review recommendations and Chief Psychiatrist standards from planning to implementation stage
3. Implement structured tools and procedures to ensure longitudinal risk factors are accessible to treating clinicians
4. Establish formal policies requiring carer/family involvement in admission and discharge planning
5. Implement mandatory follow-up within 24 hours of discharge for high-risk patients
6. Establish procedures for immediate psychiatric assessment when patients disclose suicidal ideation by telephone
7. Ensure consultant psychiatrists personally assess patients before discharge, particularly when family has expressed serious concerns
8. Implement secure smoking areas within locked wards to avoid unsecured courtyard access
9. Install personal duress alarms for staff escorting involuntary patients
10. Establish immediate alert systems for missing involuntary patients
11. Restrict access to lifts from courtyard areas to prevent unsupervised egress
12. Implement formal risk assessment documentation following any self-harm attempt while in care
13. Ensure psychiatric review within 24 hours of any self-harm attempt, including weekends
14. Establish clear procedures for contacting families regarding discharge timing, location, and arrangements
15. Implement standardised discharge planning documentation with mandatory carer signature
16. Clarify escorted ground access orders to provide specific instructions rather than discretionary language
17. Establish integrated assessment and treatment teams combining crisis response with ongoing case management
18. Ensure adequate staffing levels to prevent registrars working unsupported on critical decisions
19. Implement procedures ensuring consultant psychiatrists are consulted before discharge when family concerns exist