“Contact was made by Mr Ireland’s friend on the day of his death with the crisis team”
Dated 27 Feb 2018, from the coroner for Exeter and Greater Devon. 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 dated27 Feb 2018
- Deadline24 Apr 2018
- Published on judiciary.uk8 Jun 2018
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Devon Partnership NHS TrustNamed in the report as “Devon NHS Trust” | Response publishedPublished on judiciary.uk in June 2018. |
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The coroner’s concerns
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— (1) Contact was made by Mr Ireland’s friend on the day of his death with the crisis team. Mr ireland also spoke with them during the same telephone contact call. No advice was given that Mr Ireland could present at the emergency department should concerns continue about his mental health crisis. Had such advice been given it may have impacted on the course of events and facilitated an urgent mental health assessment. This opportunity was lost as Mr Ireland was not able to make any such decision and his friend was unaware that this was an option available with sudden onset mental health symptoms. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action.
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, 2018-0057
- 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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