“That there appears to be a breakdown in the transition and passing of information between…”
Dated 20 Feb 2015, from the coroner for Carmarthenshire and Pembrokeshire. 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 17 Apr 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 dated20 Feb 2015
- Deadline17 Apr 2015
- Published on judiciary.uk20 Feb 2015
- Today23 Oct 2026
Watch this report
We’ll email you when a response is published on judiciary.uk, or when the 56 days to reply end with none published there yet. Free, and you can stop with one click.
Responses from each recipient
| Sent to | Response |
|---|---|
| Hywel Dda University Health Board | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
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
– (1) That there appears to be a breakdown in the transition and passing of information between the Child/Adolescent and the Adult Mental Health Teams. (2) Staffing levels on the Ward need to be reviewed as it was felt that staffing resources were stretched at the relevant time (1 nurse and 3 support workers on a 16 bed acute ward). (3) There was a training need identified in relation to the section 136 procedure when patients are handed over by the Police. (4) There was a training need identified in relation to what constitutes ‘absconding’ and what should be done by staff following an incident of absconding. (5) The door policy on the Ward needs to be reviewed as a patient was able to abscond without staff noticing. (6) There was a training need identified in relation to Personality Disorders. (7) There was a training need identified in relation to powers of detention and when those powers can and should be used.
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, 2015-0092
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
Something wrong, such as a date or who it was sent to? Report a mistake
Is this report about someone close to you? You can ask us to remove names from our pages.
Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
Ask about this report
AISummaries and questions, with page references. Pro and above.
Sign in to use