“At the conclusion of the inquest, I indicated to the Properly Interested Persons that I…”

The coroner’s concerns

– At the conclusion of the inquest, I indicated to the Properly Interested Persons that I proposed to write to the Trust by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009. During the Inquiry, I received written evidence by way of a post incident review th conducted by the Trust into the death of the Deceased. On 19 December 2013 I received oral evidence from on behalf of the Trust and who was the author of the Post Incident Review. I am concerned that the review undertaken was significantly lacking for the following reasons:  CCTV footage shows that at the relevant time the Deceased shows him following another Service User out of the reception area at the hospital. It seems no steps had been taken to speak to that Service User in order to establish if he had been aware that he was a vehicle for the Deceased’s exit from hospital, and if so on what basis.  Further, the oral evidence provided to the inquiry by suggested that the review had not explored whether other service users had left the relevant ward, or the reception area of the hospital in similar circumstances. Having concluded this inquest, I now write to the Trust to confirm that in my view the Trust should take action because:  When Post Incident Reviews are undertaken it is important that they are thorough and comprehensive and that all of the relevant issues are explored prior to recommendations being made arising from that review and the organisation making recommendation for remedial action, if any, to be undertaken.  If such reviews are lacking, there is a risk that an organisation may not appreciate whether a problem is a persistent one, potentially helpful changes to procedures may not be put in place and future deaths may occur which may otherwise have been prevented. I would therefore be obliged if the Trust would write to me in due course to confirm what steps if any the Trust proposes to take to address these concerns. 2

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, 2013-0362

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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