“| report the above findings for your attention and comment with regard to action taken to…”
Dated 30 Jan 2015, from the coroner for Liverpool. 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 Mar 2015. 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 dated30 Jan 2015
- Deadline27 Mar 2015
- Published on judiciary.uk30 Jan 2015
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Cheshire and Wirral Partnership NHS Foundation Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 27 Mar 2015. 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.
— a. | report the above findings for your attention and comment with regard to action taken to prevent future deaths. b. In addition clear evidence was heard that though the therapeutic observation policy had been amended the amended policy still required the whereabouts of a patient on level 1 observations to be known but the practice was still to just record that the person was O (off the ward) as opposed to (Out with permission from a specific time going to a specific location). c. The inquest was heard in January 2015 and it was unclear from the evidence as to what training, support and professional development had been given to the staff involved and staff generally with regard to minimising the risk of recurrence of this type of tragic eventuality. . | .
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, 2015-0030
- Added to Minute Book
- 8 Oct 2026
- Reuse
- 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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