“Evidence emerged during the inquest that Mr Grieve was under the care of Stoke Talking…”
Dated 19 Mar 2025, from the coroner for Staffordshire. Sent to 3 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 14 May 2025. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated19 Mar 2025
- Deadline14 May 2025
- Published on judiciary.uk26 Mar 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Midlands Partnership University NHS Foundation TrustNamed in the report as “Midlands Partnership Foundation Trust” | Response publishedPublished on judiciary.uk in March 2025. |
| Stoke Talking Therapies | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Crisis Resolution Team | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
The coroner’s concerns
– 1. Evidence emerged during the inquest that Mr Grieve was under the care of Stoke Talking Therapies, and had also presented at the Stoke crisis Evolution Team. Both had conducted suicide risk assessments of Mr Grieve. 2. Both assessments, were incorrect, and took account of incorrect information because neither team had access to the others computer system. Stoke Talking Therapies used IAPTUS and Crisis resolution used Lorenzo. There was no way for either team to see the others electronic notes. 3. It was said in evidence, that a member of staff had not carried out a risk assessment properly whoever, nothing had been done to address this 1 and there were no plans to address this. The concern being that staff training needs are not being addressed.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0154
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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