“iam aware of the steps that have already been taken to remedy area of concern in the…”
Dated 2 Dec 2014, from the coroner for Inner 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
All responses publishedReplies were due by 27 Jan 2015.
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; a reply may have been sent and not yet published.
- Report dated2 Dec 2014
- Deadline27 Jan 2015
- Published on judiciary.uk2 Dec 2014
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| South London and Maudsley NHS Foundation Trust | Response publishedPublished on judiciary.uk in December 2014. |
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.
— iam aware of the steps that have already been taken to remedy area of concern in the Level One Investigation Report dated 15 August 2013 (draft). However, this does not address: (1) The lack of mandatory and regular glucose testing while on antipsychotic medication by the Clozapine clinic.
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, 2014-0524
- Added to Minute Book
- 8 Oct 2026
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- 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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