“The electronic Rio record system used by staff to access patient histories was introduced…”
Dated 12 Dec 2013, from the coroner for Avon. 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 publishedOrganisations 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 dated12 Dec 2013
- Published on judiciary.uk12 Sep 2013
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Responses from each recipient
| Sent to | Response |
|---|---|
| Avon and Wiltshire Mental Health Partnership NHS TrustNamed in the report as “Avon and Wiltshire Mental Health Partnership Trust” | Response publishedPublished on judiciary.uk in May 2014. |
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The coroner’s concerns
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— The electronic Rio record system used by staff to access patient histories was introduced in May 2011 when only the documentation for current patients at that date was migrated across to the new system. Discharged patients, with both a long and recent history of contact with mental health services do not appear to have had important records transferred including relapse management plans leaving staff unaware of a patients history or delaying assessments until old records can be obtained. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action. 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 7°’ November 2013.. |, the coroner, may extend the period.
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, 2013-0204
- 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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