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Coroner’s reportPrevention of future deaths · 2025-0323

“  That staff capacity of the mental health crisis team of the Gloucestershire Health…”

Dated 26 Jun 2025, from the coroner for Gloucestershire. 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.

Read the full report on judiciary.uk

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The 56-day response deadline

Deadline passed

Replies were due by 21 Aug 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.

  1. Report dated26 Jun 2025
  2. Deadline21 Aug 2025
  3. Published on judiciary.uk14 Jul 2025
  4. Today23 Oct 2026

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Gloucestershire Health and Care NHS Foundation TrustDeadline passedNo response published on judiciary.uk so far. The 56-day deadline was 21 Aug 2025. A reply may have been sent and not yet published.

The coroner’s concerns

–   That staff capacity of the mental health crisis team of the Gloucestershire Health and Care NHS Foundation Trust will dictate whether a patient is assessed on the same day when their clinical needs demand they are. That the Trust will not make any enquiries as to additional resources when their local Crisis team has no capacity.

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, 2025-0323
Added to Minute Book
8 Oct 2026
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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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