“Miss Grundy repeatedly spoke about her concern about the number of people involved in her…”
Dated 13 Mar 2019, from the coroner for Norfolk. 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 dated13 Mar 2019
- Deadline8 May 2019
- Published on judiciary.uk11 Jun 2019
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Norfolk and Suffolk NHS Foundation TrustNamed in the report as “Norfolk & Suffolk NHS Trust” | Response publishedPublished on judiciary.uk in June 2019. |
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.Miss Grundy repeatedly spoke about her concern about the number of people involved in her care, particularly from the Crisis Resolution Home Treatment Team. It is understood Miss Grundy saw 25 plus members of the Team in some 14 months. The evidence was that she found it difficult to relate to so many people, having to repeat the difficulties she was experiencing which she felt was adversely impacting on her mental health. It was not clear from the evidence that this issue was addressed during Miss Grundy’s contact with the service. . 2. This issue is referred to in the Serious Incident Requiring Investigation Report, having been raised by Miss Grundy’s family, but there is no definitive, timed action arising from it and no named person responsible for any such action. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation has the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 08 May 2019. |, the coroner, may extend the period.
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, 2019-0088
- 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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