Angela Hodes acted for the local authority in an inquest into the death of CM, a 42-year-old woman.
CM had serious mental health diagnoses and was at risk of self-neglect. She lived at home with her father who looked after her.
Once her father’s health deteriorated and he was admitted to hospital, CM was unable to function on her own. She died in July 2022.
The inquest
The coroner heard that an independent safeguarding adult review detailed missed opportunities by all relevant agencies that could have made a difference to CM’s care.
These included the relevant NHS trust, local authority adult social care and mental health services.
Coroner’s conclusion
The inquest had been adjourned for over a year for further evidence.
The senior coroner noted that the medical evidence at post mortem could not ascertain a medical cause of death; she gave a narrative conclusion and considered whether the missed opportunities had made a material contribution to CM’s death.
However, noting the marked improvements in communication between the various agencies and better training and management that had been introduced since CM’s death, the senior coroner concluded that the services operated very differently now.
Therefore a prevention of future deaths report was unnecessary.