“That the quality of the mental health risk assessment may be diminished if: quality: y…”
Dated 20 May 2015, from the coroner for West Sussex. 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 Jul 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 May 2015
- Deadline15 Jul 2015
- Published on judiciary.uk20 May 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 |
|---|---|
| Surrey and Sussex Healthcare NHS Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 15 Jul 2015. A reply may have been sent and not yet published. |
| Surrey and Borders Partnership NHS Foundation Trust | Response publishedPublished on judiciary.uk in May 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) That the quality of the mental health risk assessment may be diminished if: quality: y: (a) Mental health staff are not aware of relevant SASH policies when working at East Surrey Hospital; (b) the use of untrained staff as interpreters for mental health assessments is the norm rather than an exceptional or emergency occurrence; (c) staff members who are not health care professionals are asked to interpret during mental health assessments; (d) Staff members who are asked to interpret during mental health assessments are not given any training or guidance as to how to carry out this role. (2) Neither SASH nor SABP had considered that they should undertake a serious incident review into the case despite the death of a patient only a few hours after discharge. (a) An opportunity to learn lessons from the above events has hence been delayed and potentially been lost; (b) To decline to conduct a serious incident review because of a pre-determined opinion that there had been not been any omissions or shortcomings by the ofganisation might reflect a misunderstanding by SASH of the purpose and value of such investigations.
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, 2015-0199
- 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