“There were inconsistent accounts provided to me by two consultant psychiatrists, about…”
Dated 3 Jun 2026, from the coroner for Worcestershire. 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 29 Jul 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 dated3 Jun 2026
- Deadline29 Jul 2026
- Published on judiciary.uk28 Jul 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Herefordshire and Worcestershire Health and Care NHS Trust | Response publishedPublished on judiciary.uk in July 2026. |
The coroner’s concerns
1. There were inconsistent accounts provided to me by two consultant psychiatrists, about the relevance of reduction in smoking, rather than cessation of smoking, attributable to there being no guidance available to doctors on this issue. 2. The evidence revealed that there is no guidance on any standardised practice available to practitioners relating to asking questions and recording answers given when discussing possible symptoms of side effects of the medication. Practitioners can therefore make no record if no information is provided, which does not indicate whether questions were asked. 11. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: [please do not use individual’s names, but instead roles/titles] I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. 12. SIGNATURE Deborah LAKIN HM Assistant Coroner for Worcestershire
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, 2026-0274
- 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
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