A 70-year-old woman was discharged from a mental health team without a comprehensive risk assessment just 12 days before she took a fatal overdose, a coroner said.

Carol Robinson died at Queen’s Hospital, Romford, on May 8, 2022, the day after she took an overdose. 

Senior east London coroner Nadia Persaud has now sent a prevention of future deaths report to North East London NHS Foundation Trust (NELFT) telling it to act following Carol's death.

Carol had previously taken an overdose two months before her death, the report said, and had subsequently received care from NELFT's home treatment mental health team. 

The trust provides mental health services for people living in Barking and Dagenham, Havering, Redbridge and Waltham Forest, as well as extending out into Essex and Kent.

At an inquest which concluded on March 22, Ms Persaud raised concerns about the way Carol was discharged from that team. 

Carol was discharged back to her GP on April 25 but she was not assessed by a doctor in the home treatment team before that happened, the coroner said.

She also did not receive a comprehensive risk assessment prior to her discharge. 

Ms Persaud added: “Whilst such assessments and reviews should have taken place, it is not possible to conclude that they would have prevented her death. 

“It is noted that there were no documented concerns about her mental health between the April 26 and the May 6, 2022.” 

Ms Persaud also raised concerns that there was no multi-disciplinary team discussion to ensure a safe community plan following discharge, and that there was no communication about the home treatment team’s withdrawal with the domiciliary care agency or Carol’s family. 

Concluding the inquest, Ms Persaud said: “Mrs Robinson died as a result of an overdose of medication. The evidence does not reveal her intention at the time of taking the overdose.” 

A spokesperson for NELFT said: “We wish to offer our deepest sympathies and heartfelt condolences to Carol’s family at this very difficult time. 

“We will reflect on the coroner’s findings, to ensure that the quality of care at the trust continues to improve.” 

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