“(brief summary of matters of concern) I indicated at the conclusion of the inquest that…”
Dated 5 Sep 2025, from the coroner for Rutland and North Leicestershire. 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 31 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 dated5 Sep 2025
- Deadline31 Oct 2025
- Published on judiciary.uk16 Sep 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Leicestershire Partnership NHS Trust | Response publishedPublished on judiciary.uk in September 2025. |
The coroner’s concerns
(brief summary of matters of concern) I indicated at the conclusion of the inquest that would be making a prevention of future death report in relation to the following three areas: The extent to which additional evidence such as video footage and carers views should be taken into account. I heard evidence that work and training has been done to encourage staff to listen to careers views. However, it remains unclear as to whether any views obtained are subsequently used to inform any follow up safety plan made by the health care professionals. The extent to which staff should consider evidence provided in alternative formats such as video evidence. It was acknowledged during the inquest that recordings from mobile phones can provide helpful evidence of a patients presentation. I understood that a question had been raised internally at the trust as to what extent such evidence should be viewed, and used to inform decisions, however a final decision has not been made. Given the use of mobile phones etc in modern society, I am concerned that there is no clear guidance to staff as to how such evidence should be used. Support offered to carers who are providing support to mental health patients. It was acknowledged that carers have an important role. I heard evidence regarding mechanisms that have been put in place via systmone to record carers views, but it is unclear as to what checks are in place to ensure that carers are equipped to support patients in their home environment.
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, 2025-0454
- 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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