“The Trust's policy - in common with that of other Trusts - is that all observations…”
Dated 4 Jan 2026, from the coroner for West London. 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 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 dated4 Jan 2026
- Deadline1 Mar 2026
- Published on judiciary.uk29 Apr 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| South West London and St George's Mental Health NHS TrustNamed in the report as “South West London and St George’s Mental Health NHS Trust” | Response publishedPublished on judiciary.uk in April 2026. |
The coroner’s concerns
The Trust's policy - in common with that of other Trusts - is that all observations should include an attempt, at least, at engagement. The written logs of observations suggest that, most of the time, no attempt is made at engagement during observations, in September 2023 5 or now. Intermittent observations may be recorded as, for example, 'Corridor - pacing' because the HCA has seen the patient but not attempted to engage with the patient. General observations, once per hour, appear to be no more than a headcount to make sure all patients are present on the ward (then and now). This impression, gleaned from the documentation, appeared to be confirmed by the oral evidence of HCAs at the inquest. It appears that the general and intermittent observations on Ellis Ward are not being carried out in accordance with the Trust's policy. If this was and remains the culture on Ellis Ward, it may also be the culture on other wards operated by the Trust (since some staff work on more than one Trust ward).
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, 2026-0219
- 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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