“At the Inquest I heard various evidence about what should happen to information received…”
Dated 24 Dec 2015, from the coroner for Staffordshire (South). 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 18 Feb 2016. 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 dated24 Dec 2015
- Deadline18 Feb 2016
- Published on judiciary.uk24 Dec 2015
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| South Staffordshire and Shropshire NHS Trust | Response publishedPublished on judiciary.uk in May 2016. |
| St George's University Hospitals NHS Foundation TrustNamed in the report as “St George’s Hospital” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 18 Feb 2016. 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
(1) At the Inquest I heard various evidence about what should happen to information received from third parties concerning a person receiving treatment from the Trust. This does feature in the action plan prepared following the Inquest but I think the process should be looked at on quite a wide basis. Should information received from a third party be acknowledged at all? If so, how? How much of lengthy communications received from third parties should be recorded? Is entry on the RIO medical notes sufficient in itself? How is patient confidentiality protected in these circumstances and what about circumstances where third parties request confidentiality for information they have provided? (2) During the period that Angela was receiving assistance from the Trust there is minimal evidence of a multi-disciplinary team being involved. Predominantly one community mental health nurse took responsibility. While it may not have affected the outcome in this case a team approach involving a number of professionals may have been preferable. Is this something that the Trust needs to look at? (3) Generally the serious incident review process is a very helpful one. In this particular case however a number of concerns about Angela’s treatment were not picked up by the review. Is pressure on those carrying out this process reducing the effectiveness of the reports? 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 18 February 2016. I, the coroner, may extend the period.
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, 2015-0473
- 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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