“That there exists a shortage of suitable supported accommodation for those diagnosed with…”
Dated 25 May 2018, from the coroner for Somerset. 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
Deadline passedReplies were due by 20 Jul 2018. 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 dated25 May 2018
- Deadline20 Jul 2018
- Published on judiciary.uk22 Jun 2018
- Today27 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Somerset NHS Foundation TrustNamed in the report as “Somerset NHS Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 20 Jul 2018. A reply may have been sent and not yet published. |
| Department of Health and Social CareNamed in the report as “Department of Health” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 20 Jul 2018. A reply may have been sent and not yet published. |
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) That there exists a shortage of suitable supported accommodation for those diagnosed with Asperger's Syndrome, both in Somerset and nationally. In the case of Mr Richards this shortage resulted in him being obliged to remain on a psychiatric ward after his discharge under the Mental Health Act. This was not in Mr Richards best interests. (2) The suitability of Highbridge Court as a placement for Mr Richards which whilst CQC registered had not been CQC inspected. (3) A number of shortcomings on the part of Somerset Partnership NHS Foundation Trust (‘the Trust’) in Mr Richards mental health care were identified; a) Poor communication with family and between Trust staff. b) A lack of clarity in Mr Richards discharge plan and as to what Mr Richards could expect from his placement. c) An inadequate handover. d) Poor communication between Trust staff and Placement Staff and a failure to communicate with Mr Richards personally at a time of crisis for him. e) An inadequacy in the Trust's Risk Assessment process and subsequent management of risk to include only having telephone contact with staff and not speaking directly with Mr Richards Old Municipal Buildings, Corporation Street, Taunton, Somerset, TA1 4AQ Tel 01823 359271 | Fax 01823 355060 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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, 2018-0126
- 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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