“The nurse who assessed Liam after an episode of self harm was unaware of some of the…”
Dated 2 Jul 2014, from the coroner for South London. 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
Deadline passedReplies were due by 27 Aug 2014. A reply may have been sent and not yet published.
Organisations 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.
- Report dated2 Jul 2014
- Deadline27 Aug 2014
- Published on judiciary.uk2 Jul 2014
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| South West London and St George's Mental Health NHS TrustNamed in the report as “South West London and St George’s Mental Health Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 27 Aug 2014. A reply may have been sent and not yet published. |
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 nurse who assessed Liam after an episode of self harm was unaware of some of the significant events in Liam's history. She explained that the RiO system (an electronic patient record system used in many Trusts) did not flag up or summarise such events or primary concerns and issues in a single place, and there was insufficient time to read all of the notes (which might be voluminous) before seeing a patient. Had she been aware of the full history her actions may have been different in Liam's case, but her comments about the RiO system were general, and the difficulties are apparently encountered even today.
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, 2014-0307
- 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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