“The SHARE accommodation unit in which Mrs Gabbitas was resident over the short period…”

The coroner’s concerns

– The SHARE accommodation unit in which Mrs Gabbitas was resident over the short period prior to her death is an open residential unit operated by the Trust and the local authority in partnership; but the Trust in this case was responsible for Mrs Gabbitas’ admission and therefore it is the Trust to whom this report is addressed. I was at the inquest told that a report had been prepared within the Trust relating to Mrs Gabbitas and I was given a copy of its findings, and noted these. The following matter however was not addressed in the report. The inquest revealed a period of time on the day of her death from approximately 1.40pm to 6pm when Mrs Gabbitas was absent from SHARE, and she never returned, her body then having been discovered some distance away. Staff at SHARE were aware that she had indicated an intention to go out, but apparently were not aware of the full extent of her absence until telephoned by Mrs Gabbitas’ daughter to say her mother’s body had been found by police. It was not clear if there was any sign-in /out arrangement or any reception facility at SHARE to account for absences. I consider that, although I did not find that Mrs Gabbitas’ death would have been prevented by earlier attention to her absence, there is a risk that future deaths may occur in similar circumstances if no action is taken to record and monitor absence,albeit informally (in keeping with the nature of care in the SHARE unit), and to react appropriately to absences which appear to be inappropriate or particularly lengthy.

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, 2013-0326

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