“The deceased was discharged from hospital with 3 days prescription of her medication”
Dated 24 Sep 2013, from the coroner for County Durham and Darlington. 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
Report put online after its 56 daysOrganisations 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.
judiciary.uk put this report online on 30 Dec 2013, after the 56 days for replies had ended (19 Nov 2013). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated24 Sep 2013
- Deadline19 Nov 2013
- Published on judiciary.uk30 Dec 2013
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Tees, Esk and Wear Valleys NHS Foundation TrustNamed in the report as “Tees Esk and Wear Valley NHS Foundation Trust” | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 30 Dec 2013, after the 56 days for replies had ended (19 Nov 2013). These dates can’t tell us whether a reply was due before it went online. |
The coroner’s concerns
– (1) The deceased was discharged from hospital with 3 days prescription of her medication. In the community she had to collect her prescription on a daily basis to reduce the risk of self-harm or suicide. The Consultant Psychiatrist giving evidence at the inquest said that he was unaware of this. (2) Upon discharge the hospital did not contact the family to make them aware of her discharge even though family members had visited the deceased whilst in hospital. It may well have been that if the family had contacted the deceased upon her discharge and given support that her death could have been avoided. (3) The deceased was discharged from hospital on the Thursday and no follow up visit from a nurse was scheduled until the following Monday. The Consultant Psychiatrist attending the inquest giving evidence confirmed that this was too long a time taking into account all of the circumstances of the case and a nurse should have made contact with the deceased probably the next day or the Friday though he was unable to say whether this might have made any difference in all the circumstnaces. 1
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, 2013-0243
- 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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