“Failure to communicate in writing a Care Plan and changes to it”
Dated 27 Apr 2018, from the coroner for Inner South London. 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 Apr 2018
- Deadline22 Jun 2018
- Published on judiciary.uk1 Jul 2018
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| South London and Maudsley NHS Foundation TrustNamed in the report as “South London & Maudsley NHS Trust” | Response publishedPublished on judiciary.uk in July 2018. |
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) Failure to communicate in writing a Care Plan and changes to it. (2) Failure to provide a clear route or opportunity to challenge or appeal these changes to the Care Plan. (3) Failure to expressly communicate in writing all routes by which, to raise concerns and seek help on a non-emergency or emergency basis.
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, 2018-0136
- 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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