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Coroner’s reportPrevention of future deaths · 2016-0208

“Although Jessica had been referred to a Consultant Psychiatrist in learning disability…”

Dated 2 Jun 2016, from the coroner for Exeter and Greater Devon. 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.

Read the full report on judiciary.uk

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The 56-day response deadline

All responses published

Replies were due by 28 Jul 2016.

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.

  1. Report dated2 Jun 2016
  2. Deadline28 Jul 2016
  3. Published on judiciary.uk2 Jun 2016
  4. Today27 Oct 2026

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Responses from each recipient

Responses from each recipient
Sent toResponse
Seaton and Colyton Medical PracticeResponse publishedPublished on judiciary.uk in June 2016.
NHS Northern, Eastern and Western Devon Clinical Commissioning GroupNamed in the report as “Northern, Eastern and Western Devon Clinical Commissioning Group”Response publishedPublished on judiciary.uk in June 2016.

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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.

— 4. Although Jessica had been referred to a Consultant Psychiatrist in learning disability, the other support services offered to Jessica were main stream adult services, Jessica’s mother, a GP, is of the view that they were not equipped to deal with someone of Jessica's intellectual disabilities. 2. Perhaps Jessica’s case could be looked at to consider the appropriate pathway for others in the future in a similar situation to Jessica to give appropriate support and care at a level appropriate taking into account any learning difficulties and associated medical problems.

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, 2016-0208
Added to Minute Book
8 Oct 2026
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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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