“(brief summary of matters of concern) That Ms Tetley was removed from the inpatient bed…”
Dated 14 Sep 2025, from the coroner for Cheshire. 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 9 Nov 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 dated14 Sep 2025
- Deadline9 Nov 2025
- Published on judiciary.uk19 Sep 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Cheshire and Wirral Partnership NHS Foundation TrustNamed in the report as “Chief Executive of Cheshire and Wirral Partnership NHS Trust” | Response publishedPublished on judiciary.uk in September 2025. |
The coroner’s concerns
(brief summary of matters of concern) That Ms Tetley was removed from the inpatient bed list on the 25 June at 10:37 hours before an attempted review by a mental health practitioner at 11:30 hours the same day. Following daily documented reviews between the 18 June 2024 to the 24 June 2024, it was documented that Ms Tetley required inpatient admission and daily reviews. I am concerned that there is a risk that patients are removed from the inpatient bed list before an appropriate review that day, by a mental health professional.
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, 2025-0466
- 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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