“(brief summary of matters of concern) One of the findings of the the Patient Safety…”
Dated 22 Dec 2025, from the coroner for Northamptonshire. 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
Report put online after its 56 daysOrganisations 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.
judiciary.uk put this report online on 18 Mar 2026, after the 56 days for replies had ended (16 Feb 2026). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated22 Dec 2025
- Deadline16 Feb 2026
- Published on judiciary.uk18 Mar 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Northamptonshire Healthcare NHS Foundation Trust | Response publishedPublished on judiciary.uk in March 2026. |
| NHS Northamptonshire Integrated Care BoardNamed in the report as “Northamptonshire Integrated Care Board” | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 18 Mar 2026, after the 56 days for replies had ended (16 Feb 2026). These dates can’t tell us whether a reply was due before it went online. |
The coroner’s concerns
(brief summary of matters of concern) One of the findings of the the Patient Safety Incident Investigation (PSII) was that “.. there is no protocol for patients open to private and NHS psychiatry at Northamptonshire Healthcare Foundation Trust. The Psychiatrist’s role in patient care is to review and recommend appropriate medication and it is problematic if two Consultants are overseeing this at the same time. It can cause confusion and detriment to the patient if medication changes are not communicated between parties and represents a risk to patient safety… It Regulation 28 – After Inquest Document Template Updated 30/07/2021 is notable that CMHT operational managers from across the service differ in their views on the appropriateness of a patient being open to NHS and private services at the same time..”. It also emerged at Inquest that a NHS Consultant may not be aware that the patient is also receiving private psychiatry. Where the GP is notified of private psychiatry, it does not trigger a notification to NHS mental health services. Notification of the dual treatment may then be entirely dependent upon the information being shared by the patient.
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, 2026-0153
- 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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