“In respect of the in-patient management: that there was no separate policy or guidance…”
Dated 5 Dec 2016, from the coroner for South London. 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
Report put online after its 56 daysOrganisations 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.
judiciary.uk put this report online on 12 Feb 2017, after the 56 days for replies had ended (30 Jan 2017). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated5 Dec 2016
- Deadline30 Jan 2017
- Published on judiciary.uk12 Feb 2017
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Resuscitation Council (UK) | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 12 Feb 2017, after the 56 days for replies had ended (30 Jan 2017). These dates can’t tell us whether a reply was due before it went online. |
| South London and Maudsley NHS Foundation TrustNamed in the report as “South London and Maudsley NHS Trust” | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 12 Feb 2017, after the 56 days for replies had ended (30 Jan 2017). These dates can’t tell us whether a reply was due before it went online. |
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) In respect of the in-patient management: that there was no separate policy or guidance, other than a pictorial wall chart, regarding the assessment and management of risks posed by items that might be used to cause self harm. The complexities of managing these risks on an adolescent in-patient psychiatric unit were not therefore adequately considered, and this led to a lack of clarity and consistency. 2 With regard to resuscitation: the emergency equipment on the unit did not include a laryngoscope. The item obstructing Christopher's airway was subsequently used by ambulance personnel using Magill forceps with a laryngoscope, and this combination had been successfully used on a previous occasion when Christopher had swallowed a bottle top. Laryngoscopes are not part of the standardised items on the unit, and are not included in the Resuscitation Council guidance for mental healthcare settings. It has been suggested that this is because they are complex devices that require intense training and competency assessments before staff can use them, and that it may be counterproductive to make them available. However, in view of the circumstances of Christopher's death, and the apparent prevalence of self harm in adolescent units, the matter is reported for consideration, both in relation to the laryngoscope itself and the access to staff trained in its use.
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, 2016-0433
- Added to Minute Book
- 8 Oct 2026
- Reuse
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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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