“I am concerned that five years after the death of Mr Laversuch there is not in place a…”

The coroner’s concerns

I am concerned that five years after the death of Mr Laversuch there is not in place a clear and readily understandable policy framework and guidance for the admission of patients into wards after their detention has been authorised under the Mental Health Act and that there remains, on the evidence heard at inquest, a failure by some staff to understand what is required of a safe risk assessment. I recognise and accept that there have been efforts to learn from Richard’s death and formulate the appropriate guidance, but I am concerned that they are still not clear so long after his death. I am concerned that a patient who poses a significant risk to themselves and others may be admitted to ward unsuited to their risk and that there is a risk of future deaths. 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: of Richard Laversuch of Mr X Hampshire County Council Hampshire and Isle of Wight Healthcare NHS Trust The Approved Mental Health Practitioner 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 Nicholas WALKER HM Area Coroner for Hampshire, Portsmouth and Southampton

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, 2026-0415

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20 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