“Kerria Court residential home (1) The care plan for Mr Harris did not deal with his risk…”
Dated 3 Aug 2016, from the coroner for Birmingham and Solihull. 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
All responses publishedReplies were due by 28 Sep 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.
- Report dated3 Aug 2016
- Deadline28 Sep 2016
- Published on judiciary.uk3 Aug 2016
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Sandwell and West Birmingham Hospitals NHS Trust | Response publishedPublished on judiciary.uk in August 2016. |
| Birmingham City Council | Response publishedPublished on judiciary.uk in August 2016. |
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.
— Kerria Court residential home (1) The care plan for Mr Harris did not deal with his risk of absconding. As a result when he was transferred to City Hospital with his care plan there were no details of his previous absconding behaviour. (2)When Mr Harris was transferred to hospital, without an escort, there was no written documentation provided to confirm that a DOLS had been applied for and that he was an absconding risk. Sandwell and West Birmingham Hospitals NHS Trust (3) At no time did staff consider if Mr Harris should be subject to an emergency DOLS despite him having dementia and having tried to leave the ward on 16/03/2016. He had previously been assessed as requiring and DOLS. Birmingham City Council (4) The application for DOLS order was not processed before Mr Harris's death. | heard evidence that it often takes many months to process a DOLS application. Given these are extremely vulnerable people applications should be processed more quickly.
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
- 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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