THE NHS has said it won't make any changes to stop more deaths despite discharging a patient who later died.

Senior coroner for Herefordshire Mark Bricknell said the Herefordshire and Worcestershire Health and Care NHS Trust, which runs the Stonebow Unit near Hereford County Hospital, should make changes to prevent future deaths.

In a report to the NHS, he said Terri Ann Malone's death in 2022 was alcohol-related, but she had died after being discharged.

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He said patients' initial contact with the NHS's Healthy Minds team was with an inexperienced practitioner and a decision was made regarding a treatment plan without any direct contact being made by an experienced practitioner.

They can then be discharged from the service after failing to attend an appointment, or respond to a voicemail, despite being made to wait "several months" for an appointment.  A person's circumstances at the time are also not established.

The NHS was given a deadline to reply, but chief executive Sarah Dugan stood by the actions taken before Ms Malone's death.

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In a long reply to the coroner's prevention of future deaths report, she outlined the national model of increasing access to psychological therapies (IAPT) programme.

She said this approach had been followed and Healthy Minds was appropriate for the patient.

She said Ms Malone was motivated, engaged with Turning Point, an alcohol and drug support service, and had reduced her alcohol intake.

From the initial assessment, Ms Malone faced a nine-week wait for treatment, which gave her an "opportunity to demonstrate that her alcohol usage hadn’t increased and become a problem again".

There was also no evidence of severe mental illness or risks identified at the time of assessment.

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Ms Malone had also been assessed by the neighbourhood mental health team and no more action was needed.

Ms Dugan said she recognised the coroner's concern that Ms Malone was discharged when she did not attend her treatment appointment, but this was in line with guidance.

The NHS had sent information to the patient after the missed appointment and their GP could follow up if there was a concern.

She said: "Whilst I accept the concerns that you have raised, taking into account the IAPT approach and circumstances of the case, I am satisfied that the actions taken in terms of this patient were appropriate."