“, — (1) The Devon Partnership trust had no adequate mental health care for Louise after…”
Dated 7 Sep 2016, from the coroner for Exeter and Greater Devon. Sent to 3 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 2 Nov 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 dated7 Sep 2016
- Deadline2 Nov 2016
- Published on judiciary.uk7 Sep 2016
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| NHS Northern Eastern and Western Clinical Commissioning Group | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Department of Health and Social CareNamed in the report as “Department of Health” | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Devon Partnership NHS TrustNamed in the report as “Devon Partnership Trust” | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
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) The Devon Partnership trust had no adequate mental health care for Louise after she was discharged. There was inadequate contact and no explanation at Inquest as to why this had not taken place. (2) The duty system arrangements and buddying system referred to at Inquest were not effective or robust and need to be reconsidered in the light of the outcome of this case. (3) There was a suggestion at Inquest that the patients themselves were expected to be in charge of making contact. In cases of severe mental health, this does not appear to be appropriate or realistic, and the Devon Partnership Trust should reconsider this and/or the training of their staff who hold this bellef. (4) There are no female intensive care beds for psychiatric patients in Devon. This does not match the desired parity of mental health care with physical heaith care. Devon Partnership Trust needs to consider future planning and provision fo ensure the needs of patients can be met.
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, 2016-0322
- 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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