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You are in the PFD Zone

Melvyn Blount

2023-0345

Prevention of Future Deaths Report

Coroner

Coroner's area

Date of report

Read the PFD report for

Susan Evans

Derby and Derbyshire

21 September 2023

Report recipients

MH team (community healthcare trust)

GP practice

Issues raised

2.1.2. Failure to communicate - internal (within own team)

2.1.3. Failure to communicate - external (other teams, services, professions, organisations)

2.3.1. Information not sought; lack of professional curiosity; capacity not considered

2.3.3. Cycle of Doom; no multi-disciplinary team; no lead professional

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