“Evidence was heard that Mr Brown’s care records were not reviewed prior to his being…”
Dated 15 Apr 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 dated15 Apr 2019
- Deadline10 Jun 2019
- Published on judiciary.uk14 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. Evidence was heard that Mr Brown’s care records were not reviewed prior to his being seen, which would enable Mr Brown’s full history and risks to be taken into account when assessing him. 2. This is a matter which has been raised with the Trust previously. Staff are expected to read previous records relating to a service user, but this is not always happening. 3. This matter was not considered in the otherwise thorough investigation conducted by the Trust. 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 10 June 2019. I, 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
- Added to Minute Book
- 8 Oct 2026
- Reuse
- 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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