“Page 2 of 4 NHS England 1”
Dated 17 Feb 2025, from the coroner for Hertfordshire. 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
All responses publishedOrganisations 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 dated17 Feb 2025
- Deadline14 Apr 2025
- Published on judiciary.uk17 Apr 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| NHS England | Response publishedPublished on judiciary.uk in April 2025. |
| NHS Hertfordshire and West Essex Integrated Care BoardNamed in the report as “Hertfordshire & West Essex Integrated Care Board” | Response publishedPublished on judiciary.uk in April 2025. |
| Hertfordshire County Council | Response publishedPublished on judiciary.uk in April 2025. |
The coroner’s concerns
Page 2 of 4 NHS England 1. That, nationally, waiting times for ASD assessments are very long. Such assessments are important in guiding effective care and treatment, as well as being a potential gateway to access other relevant services. This combined with the fact of an increased risk of suicidal behaviour amongst those who receive a diagnosis of ASD, gives rise to a concern that future deaths may occur on account of the delays in ASD assessment. Hertfordshire Integrated Care Board 2. That whilst the local mental health Trust has plans to reform the manner in which ASD assessments for patients under their care are undertaken, the implementation of those plans awaiting input from the Integrated Care Board. This means that waiting times for ASD assessments in Hertfordshire remain lengthy which in turn gives rise to a risk of future deaths occurring for the reasons set out above. Hertfordshire County Council 3. That the safety measures in place on the to guard against pedestrians either jumping or falling from the bridge do not meet current guidance, and therefore gives rise to a risk of future deaths occurring.
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, 2025-0187
- 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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