“The suggestion made to Ms”
Dated 4 Mar 2015, from the coroner for Avon. Sent to 2 organisations or people.
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 29 Apr 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 dated4 Mar 2015
- Deadline29 Apr 2015
- Published on judiciary.uk4 Mar 2015
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Avon and Wiltshire Mental Health Partnership NHS Trust | Response publishedPublished on judiciary.uk in March 2015. |
| Care Quality Commission | Response publishedPublished on judiciary.uk in March 2015. |
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.
— (1) The suggestion made to Ms. Parsons, a person with a history of self harming and who remained at high risk of self-harming, that she could be assisted with self- harming was not an approach to patient care and treatment which was supported by any reference to the results of any research published in a peer-reviewed professional journal. Therefore if this is a bona fide approach to treatment in a high risk patient then the Trust should be able to justify that this is a recognised and generally accepted practice by reference to the published literature and/or results of published research. (2) If the Trust cannot provide evidence to support this treatment being a recognised and generally accepted practice then the Trust must establish proper procedures for the introduction and use of novel treatments including the obtaining of any necessary ethical approvals. (3) This discussion with regard to ‘assisted self-harming’ was not discussed by the nurse with the consultant psychiatrist nor was any record made of the discussion. The Trust should undertake a proper review of any training with respect to these matters so as to ensure any discussions with regard to proposed treatment are had with the full knowledge and agreement of the consultant in charge and that those discussions are properly recorded.
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, 2015-0077
- Added to Minute Book
- 8 Oct 2026
- Reuse
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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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