“I heard evidence that there had been changes to the policies and templates aimed at…”
Dated 8 Aug 2025, from the coroner for Inner West 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 3 Oct 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 dated8 Aug 2025
- Deadline3 Oct 2025
- Published on judiciary.uk13 Aug 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| South West London and St George's Mental Health NHS TrustNamed in the report as “South West London and St Georges Mental Health NHS Trust” | Response publishedPublished on judiciary.uk in August 2025. |
The coroner’s concerns
I heard evidence that there had been changes to the policies and templates aimed at addressing risk around leave and safety off ward. This was still ongoing. It was accepted in evidence that the acute ward operational policy and leave policy needed to be reviewed again to makes sure the various polices including risk management policies were aligned. For example on the Day 2 checklist for review there was no placeholder for leave/off ward safety management. I was told that there was a positive move to review thinking around risk more as safety rather than simply as risk management, but this was a new concept. I noted that in the templates now used to consider nursing reviews and handovers, there was no specific place to consider leave management and safety around this, expecting it instead to be addressed in the plan – albeit there was a reminder to consider this on the template. To that extent it appeared little substantial had changed from the process before, and the policies remained unaligned. I am concerned that safety planning around leave/going off ward/unit as a voluntary patient has not been given the prominence it requires, as was required in the case of Gareth where the plan for his safety 4 off ward had not been identified by staff on Ward 2 effectively. As such my concern as to future death if this were to not to be unaddressed comprehensively, continues.
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, 2025-0417
- Added to Minute Book
- 7 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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