“5 (1) The inquest heard there were only two attempts to see Claire by the enhanced…”
Dated 24 Mar 2025, from the coroner for South Yorkshire West. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 19 May 2025.
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; a reply may have been sent and not yet published.
- Report dated24 Mar 2025
- Deadline19 May 2025
- Published on judiciary.uk27 Mar 2025
- Today29 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| South West Yorkshire Partnership Teaching NHS Foundation TrustNamed in the report as “South West Yorkshire Partnership NHS Foundation Trust” | Response publishedPublished on judiciary.uk in March 2025. |
The coroner’s concerns
– 5 (1) The inquest heard there were only two attempts to see Claire by the enhanced community mental health team between 28 November 2023, when she was seen in police custody, and 16 January 2024, when she was detained under the Mental Health Act, despite clear evidence her mental health was deteriorating. It was accepted in evidence a more assertive approach to attempt to engage Claire, and in complex cases generally, could have been used and there could have been better liaison between the police and the enhanced community mental health team when Claire was in custody. A more assertive approach and better liaison could have prevented Claire relapsing to such an extent she needed to be detained under the Mental Health Act. (2) The inquest heard that training on the effect of substance misuse on mental health conditions is not mandatory for all staff and would be of assistance when caring for patients such as Claire.
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, 2025-0161
- Added to Minute Book
- 8 Oct 2026
- Reuse
- 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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