“Lack of updated Risk Assessments when key events occurred or there was a significant…”
Dated 29 Nov 2016, from the coroner for South Yorkshire East. Sent to 1 organisation or person.
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 publishedOrganisations 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 dated29 Nov 2016
- Deadline24 Jan 2017
- Published on judiciary.uk12 Feb 2017
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| The Rotherham NHS Foundation TrustNamed in the report as “Rotherham NHS Trust” | Response publishedPublished on judiciary.uk in February 2017. |
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The coroner’s concerns
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— (1) Lack of updated Risk Assessments when key events occurred or there was a significant deterioration in presentation. (2) Failure of the care co-ordinator to identify changes in presentation and level of risk and to seek a doctors input. Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS Tel 01302 737135 | Fax 01302 736365 (3) Absence of an effective and robust system to identify and then manage patients under the care of departing staff (for example care co-ordinator). (4) Lack of effective communication between mental health professionals at differing levels and also between those professionals and the patient and the patient’s family. (5) Difficulty in consultant psychiatrists accessing Home Treatment Team Services when they indicate a need (since a change in emphasis in interpreting the guidelines from the end of 2014).
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, 2016-0429
- Added to Minute Book
- 8 Oct 2026
- Reuse
- 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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