“S are as follows: (brief summary of matters of concern) At the Inquest it was highlighted…”
Dated 9 Apr 2019, from the coroner for Suffolk. 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 dated9 Apr 2019
- Deadline4 Jun 2019
- Published on judiciary.uk18 Jun 2019
- Today23 Oct 2026
Watch this report
We’ll email you when a response is published on judiciary.uk, or when the 56 days to reply end with none published there yet. Free, and you can stop with one click.
Responses from each recipient
| Sent to | Response |
|---|---|
| Norfolk and Suffolk NHS Foundation TrustNamed in the report as “Norfolk and 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
S are as follows: (brief summary of matters of concern) At the Inquest it was highlighted the following could have been done to try and prevent his death 1/ Daily visits from the mental health team 2/ Involvement of the next of kin (his father) 3/ Formal mental health act assessment 4/ Involvement of the practice nurse 5/ Use of Corner house care facility 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have 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 June 03, 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, 2019-0123
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
Something wrong, such as a date or who it was sent to? Report a mistake
Is this report about someone close to you? You can ask us to remove names from our pages.
Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
Ask about this report
AISummaries and questions, with page references. Pro and above.
Sign in to use