“The absence of a formal documented s.117 plan agreed by all those responsible for a…”
Dated 21 Nov 2025, from the coroner for Worcestershire. Sent to 2 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 publishedOrganisations 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 dated21 Nov 2025
- Deadline16 Jan 2026
- Published on judiciary.uk23 Feb 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Birmingham and Solihull Mental Health NHS Foundation TrustNamed in the report as “Birmingham and Solihull Mental Health Foundation Trust” | Response publishedPublished on judiciary.uk in February 2026. |
| NHS England | Response publishedPublished on judiciary.uk in February 2026. |
The coroner’s concerns
– (1) The absence of a formal documented s.117 plan agreed by all those responsible for a patient’s care and treatment upon discharge into the Community from a lengthy inpatient stay creates a risk of disjointed, disorganized and inadequate support for vulnerable people suffering serious mental health conditions. This, in turn, may cause them to feel unsupported and helpless. BSMHFT did not provide a Plan despite requests to do so. S.117 is intended to ensure that patients receive planned and structured support tailored to their requirements. Such planning was absent in this case. (2) I was informed by the Representative of BSMHFT that there is no national guidance from the NHS or other source that explains what a s.117 plan should address. If so, this represents a lacuna which gives rise to concern that mental health providers are unclear as to the component elements for a s.117 plan and the degree or depth of planning required for individual patients. 6
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, 2026-0101
- Added to Minute Book
- 8 Oct 2026
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- 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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