“In my opinion, the following matters give rise to a concern that there is a risk of…”

The coroner’s concerns

In my opinion, the following matters give rise to a concern that there is a risk of future deaths. a) Proactive scope of risk assessment for impulsive ingestion (CWPT) The evidence raised a concern that risk assessments may focus primarily on specific previously ingested items, rather than undertaking a sufficiently proactive assessment of a wider range of swallowable items within the inpatient environment. Where a patient is known to present a persistent risk of impulsive ingestion, a predominantly reactive approach risks foreseeable hazards not being identified and mitigated in advance. b) Interface working and demonstrable liaison between mental health and acute services (CWPT and UHCW) The evidence before the inquest disclosed limited detail demonstrating how liaison, shared responsibility, and specialist input are consistently achieved in practice when a mental health inpatient is transferred to an acute hospital for physical healthcare. While both organisations described mechanisms for access to advice and communication, there was relatively limited evidence of how these arrangements operate reliably, how compliance is assured, and how lapses are detected and addressed. This creates a risk that relevant mental health risks are not consistently carried through the acute admission. c) Assurance and auditing of expected communication processes (CWPT) The evidence raised concern that processes described as standard practice, including regular contact following transfer, may not be subject to routine auditing or assurance. Reliance on the existence of a process alone, without effective oversight of whether it is consistently carried out in practice, risks failures persisting undetected. 7. ACTION In my opinion, action should be taken to prevent future deaths, and I believe your organisations have the power to act. 8. RESPONSE You are under a duty to respond to this report, setting out what consideration you have given to the concerns raised, namely by [date].(assuming this goes out tomorrow it is 56 days from that date -9 July 2026) 9. COPIES A copy of this report is being sent to the Chief Coroner. It may be published on the judiciary website. It is also being sent to the following Interested Persons: • The family of the deceased Linda Lee Acting Area Coroner for Coventry and Warwickshire 14 May 2026

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, 2026-0267

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