“There were consistent and repeated incidents (13 incidents in 6 days) where leave from…”

The coroner’s concerns

- 1. There were consistent and repeated incidents (13 incidents in 6 days) where leave from the ward was granted without any documented mental state examination or risk assessment being undertaken prior to the patient being permitted to leave the ward. 2. There was poor documentation throughout the medical records with entries lacking detail, being added retrospectively (up to two days later) without any explanation or referencing the retrospective nature of the entry. 3. The Patient Safety Incident Investigation authors were unfamiliar with the medical records system which lead to the retrospective entries not being identified correctly, therefore the investigation did not make any finding. However, with more understanding, it is likely the retrospective entries in the medical records who have been identified and their relevance realised which would have altered the content and findings of the report. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you Mr Lewis have the power to take such action. 7. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Tuesday the 12th May 2026. 1, the coroner, may extend the period.

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, 2026-0165

Added to Minute Book

8 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