“During the course of the Inquest the evidence revealed matters giving rise to concern”
Dated 13 Dec 2019, from the coroner for East London. 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 7 Feb 2020.
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 dated13 Dec 2019
- Deadline7 Feb 2020
- Published on judiciary.uk13 Dec 2019
- Today28 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| North East London NHS Foundation TrustNamed in the report as “North East London Hospital Trust” | Response publishedPublished on judiciary.uk in December 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.
During the course of the Inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The matters of concern are as follows: 1. Sammi was cared for under the Access Assessment and Brief Intervention Team (AABIT). She was under the care of this team for almost three years. Her care requirements went beyond “brief intervention”. Whilst under the care of this team, Sammi had no overarching care plan. No-one was appointed to oversee Sammi's care. The evidence at the Inquest revealed that doctors working within the team were not aware of the possibility of service users under the AABIT having an overarching care plan or of service users having a key- worker assigned to them. 2. Sammi suffered from emotionally unstable personality disorder and mood congruent psychotic symptoms. She required psychotherapy treatment. She was referred to the psychotherapy services in March 2017. By the time of her death in February 2018, Sammi had not received psychotherapy. The Inquest heard that there could be delays of 17 months from referral to receipt of treatment. It is considered that these ongoing lengthy delays give rise to a risk of future deaths.
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, 2019-0483
- 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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