“(brief summary of matters of concern) (1) Whilst evidence was given at the Inquest of…”

The coroner’s concerns

(brief summary of matters of concern) (1) Whilst evidence was given at the Inquest of fresh and additional learning that had arisen during the coronial investigation and as a result of the evidence given in person by Oxford Health staff and others, it was clear that the initial Incident Learning Huddle and subsequent Patient Safety Incident Investigation (PSII) undertaken in 2024 lacked robustness and did not appear to have been revisited in the light of the emerging family concerns and evolving evidence during the coronial investigation. The need for proactive backwards reflection on internal investigations is essential in informing learning going forward. (2) At the Inquest there was variable evidence as to the operation of the daily Patient Flow Meetings, during which patients requiring beds would be matched to availability based on individual needs. Communication to families of issues or obstructions to bed availability and reinforcement of safety plans during any period of wait for a bed should be a central feature of these daily meetings. (3) The fact that Barry had not had any face to face psychiatric review at any point during the time he was open to Oxford Health was not addressed in the PSII and it remains unclear how this can be escalated for immediate attention in the community, where circumstances are changing, where the need for a voluntary admission has been agreed, but no bed is available. (4) Evidence confirms that Oxford Health has access to the same Trust bed spaces in Buckinghamshire and Oxfordshire for detained and voluntary patients, within and without the older adult criteria, however the evidence indicated that bed availability as part of an agreed or prescribed care and treatment plan remains a significant issue. (5) Evidence from Oxford Health, acknowledged in a candid manner, that the Trust had listened to witnesses and the family during the Inquest and there was more to be taken back to identify further actions to be implemented. The broader issues of consistent understanding within and between Trust teams and with proactive communication with patients in the community and their families will remain of concern if they are not addressed in policy and training going forward. The very fact that learning was still being discussed and identified in January 2026 when Barry died in April 2024 indicates the importance of the timely implementation of identified actions

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, 2026-0203

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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