“The Mersey Care Policy and Procedure for leave for an informal patient was ratified in…”
Dated 14 Oct 2013, from the coroner for Liverpool. Sent to 2 organisations or people.
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 26 Jan 2014, after the 56 days for replies had ended (9 Dec 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 dated14 Oct 2013
- Deadline9 Dec 2013
- Published on judiciary.uk26 Jan 2014
- Today22 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Mersey Care NHS Foundation TrustNamed in the report as “The Chief Executive, Mersey Care” | Response publishedPublished on judiciary.uk in January 2014. |
| NHS Trust | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 26 Jan 2014, after the 56 days for replies had ended (9 Dec 2013). These dates can’t tell us whether a reply was due before it went online. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— The Mersey Care Policy and Procedure for leave for an informal patient was ratified in October 2006 and was due for review in October 2007. It has not been reviewed. The. policy does not reflect practice. The policy needs to be updated immediately to protect patients and to be fair to employees of Mersey Care. To reflect current practice the policy should reflect amongst other matters that leave is permitted when observations are reduced to level 1 and there has been a multidisciplinary team consensus that a regime of leave is appropriate having consideration to (i) the deceased’s vulnerability, (ii) the fact that the hospital had assumed responsibility for the patient's welfare and safety, including by the exercise of control, and (iii) the nature of the risk and whether it was “exceptional” rather than “ordinary” The policy should include stressing the importance of documenting before leave the time of taking leave and when the patient is due back. The operation of the policy should be audited to ensure compliance. a
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, 2013-0239
- 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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