Sophie Boothe

with, or input from, the mental health services. Both of Sophie's parents acknowledged that she was manipulative in this regard. The plan following this telephone assessment was to discharge Sophie at that time, but with signposting to further support should she feel that she needed it. Sophie's mother remained concerned at attended the GP to discuss Sophie on the 18th June 2019 as a result of which the GP re-referred Sophie to the CPE . Sadly, no further assessment could be made as Sophie was reported missing by her family later that afternoon. She was discovered on the 19th June 2019 at a hotel in Hook, where she had checked in, alone, the night before. The post-mortem result revealed that Sophie had died as a result of toxicity. 5 CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken . In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. - It became very clear in evidence that the overseas involvement was not properly flagged up when the CPE came to triage Sophie's referral; this includes both the discharge summary and Sophie's own self-referral via email whilst she was in Australia. The full discharge summary from Australia was sent by the GP along with his referral on the 8th May 2019 to ensure that all relevant information was shared at the earliest stage. These notes were either not fully reviewed and/or understood by the CPE and this appears to have contributed to the downgrading of Sophie's referral. It became clear in evidence that the UK services did not understand that "Scheduled" is the Australian equivalent of being "Sectioned" and there was a lack of probity and curiosity to as what this meant and what treatment Sophie had in Australia; albeit that the evidence was not convincing (or even persuasive) that the Australian discharge summary had been thoroughly read at all on being received by the CPE . Overall, there appears, on the evidence, to be very poor communication between the departmental services and, as a result, opportunities appear to have been missed to fully appreciate Sophie's full clinical presentation when making an assessment about the timeliness of appropriate interventions and assessments. I believe that whilst the service remains disjointed, with insufficient exploration of information sent from foreign jurisdictions, there remains a risk that future death will continue to occur. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you AND/OR your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 27th April 2020. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons who may find it useful or of interest: