“I heard evidence from a Flow Coordinator who was responsible for taking the practical…”
Dated 14 Apr 2026, from the coroner for Cumbria. 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 Jun 2026.
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 Apr 2026
- Deadline9 Jun 2026
- Published on judiciary.uk29 Apr 2026
- Today27 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| North Cumbria Integrated Care NHS Foundation Trust | Response publishedPublished on judiciary.uk in April 2026. |
The coroner’s concerns
– (1) I heard evidence from a Flow Coordinator who was responsible for taking the practical steps to arrange a patient's discharge after the treating clinicians had determined that the patient was medically fit. I understand that the Flow Coordinator is to make the necessary logistical arrangements for discharge, not to decide whether discharge is appropriate. However, the evidence was that the Flow Coordinator would not necessarily be briefed on any particular vulnerabilities that a patient had. For instance, in this instance Mr Stewart had made repeated threats to harm himself, including on the railway, which the Flow Coordinator did not know of. She considered making arrangements for him to travel home by train, which might have been especially risky. Whilst these matters did not eventuate in this inquest, I consider that not giving Flow Coordinators information about patient vulnerability risks them making unsuitable arrangements. 6) ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you North Cumbria Integrated Care NHS Foundation Trust 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 10th June 2026 . I, 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, 2026-0221
- 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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