“(brief summary of matters of concern) 1) Current resources for safeguarding those with…”
Dated 28 May 2025, from the coroner for Teesside and Hartlepool. Sent to 7 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 publishedReplies were due by 23 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 dated28 May 2025
- Deadline23 Jul 2025
- Published on judiciary.uk30 May 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Department of Health and Social Care | Response publishedPublished on judiciary.uk in May 2025. |
| NHS North East and North Cumbria Integrated Care BoardNamed in the report as “Integrated Care Board (NHS North East and North Cumbria)” | Response publishedPublished on judiciary.uk in May 2025. |
| Tees Esk and Wear Valley NHS Mental Health Foundation Trust | Response publishedPublished on judiciary.uk in May 2025. |
| Middlesbrough Council | Response publishedPublished on judiciary.uk in May 2025. |
| Stockton Council | Response publishedPublished on judiciary.uk in May 2025. |
| Hartlepool Council | Response publishedPublished on judiciary.uk in May 2025. |
| Redcar Council | Response publishedPublished on judiciary.uk in May 2025. |
The coroner’s concerns
(brief summary of matters of concern) 1) Current resources for safeguarding those with mental health illnesses whilst intoxicated may be placing people at risk. 2) I heard evidence that a person who was suicidal, suffering with mental health concerns and was intoxicated could not be adequately safeguarded until he was sufficiently sober to allow a mental health assessment.
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, 2025-0248
- 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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