“He was known to have suicidal ideation but no actual plan had been formulated”
Dated 20 Apr 2015, from the coroner for Wiltshire and Swindon. 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
Deadline passedReplies were due by 15 Jun 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 Apr 2015
- Deadline15 Jun 2015
- Published on judiciary.uk20 Apr 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 April 2015. |
| Department of Health and Social CareNamed in the report as “Department of Health” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 15 Jun 2015. A reply may have been sent and not yet published. |
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.
— He was known to have suicidal ideation but no actual plan had been formulated. | did not find that he ought to have been admitted. My concern however is that had he needed admitting it is apparent no beds would have been available at Green Lane Hospital Devizes when an enquiry was made on 6 July 2014 by North Wiltshire Intensive Services. Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 | Fax 01722 332223 ACTION SHOULD BE TAKEN What action would there have been taken in that eventuality? Would enquiries have been made as to the availability of other beds in other areas such as Callington Road, Bristol?
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, 2015-0147
- 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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