“are: The system for considering correspondence received from GPs, including requests for…”
Dated 14 Dec 2017, from the coroner for Surrey. 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 publishedReplies were due by 8 Feb 2018.
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; a reply may have been sent and not yet published.
- Report dated14 Dec 2017
- Deadline8 Feb 2018
- Published on judiciary.uk22 Dec 2017
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Surrey and Borders Partnership NHS Foundation TrustNamed in the report as “Surrey and Borders Partnership NHS Trust” | Response publishedPublished on judiciary.uk in December 2017. |
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
are: The system for considering correspondence received from GPs, including requests for medication reviews, appears to remain the same as the system which was in place at the time of Mr Smith’s death and which failed to identify request for a medical review on 7 March 2016. There are a number of CMHRS service users who, like Mr Smith, are not under the CMHRS medical team, but whose care is led by other members of the multi-disciplinary team, including clinical psychologists and care co-ordinators. The court heard that there is a clear system in place in the medical team for updating GPs on progress and also in the event of failures to attend appointments (DNAs). However, it did not appear to the court that there was a clear system for updating GPs when the medical team was not involved in a patient’s care. This risks GPs being unaware, as was in this inquest, of instances in which their patient begins to display signs of disengagement with the service. Consideration should be given to whether any steps can be taken to address the above concerns.
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, 2017-0459
- 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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