“Evidence emerged during the inquest that there were failures to properly implement…”
Dated 29 Mar 2018, from the coroner for Black Country. 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
Deadline passedReplies were due by 24 May 2018. A reply may have been sent and not yet published.
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.
- Report dated29 Mar 2018
- Deadline24 May 2018
- Published on judiciary.uk29 Mar 2018
- Today22 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Walsall Healthcare NHS Trust | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
The coroner’s concerns
– 1. Evidence emerged during the inquest that there were failures to properly implement sufficient training for staff during the introduction of a new IT system (Lorenzo). This resulted in the premature closing of her access plan and effectively no further review. This failure to conduct a review led to a number of patients including Mrs Spencer being placed at risk of harm.
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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