“There was no clear and documented care plan in place whilst Mr Fraser was under the care…”
Dated 23 May 2025, from the coroner for East London. 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 18 Jul 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 dated23 May 2025
- Deadline18 Jul 2025
- Published on judiciary.uk29 May 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| North East London NHS Foundation TrustNamed in the report as “North East London Foundation Trust” | Response publishedPublished on judiciary.uk in May 2025. |
The coroner’s concerns
(1) There was no clear and documented care plan in place whilst Mr Fraser was under the care of the Mental Health and Wellness Team. There was a lack of structure to the care provided to Mr Fraser by the Mental Health and Wellness Team. (2) There was no robust risk assessment carried out by the Mental Health and Wellness team. (3) The Mental Health and Wellness Team had been unable to reach Mr Fraser from the 16 July 2024. On the 18 July 2024 a friend contacted the mental health team to raise concern about his lack of contact with Mr Fraser. No action was taken at this time to review the risk of harm to Mr Fraser or to determine whether the Trust’s missing person procedure should be activated. There was no meaningful contact with the family to report the concerning lack 2 of contact with Mr Fraser, until the 29 July 2024.
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, 2025-0247
- 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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