“The findings of the internal investigation by Oxleas NHS were that the assessment…”
Dated 21 Feb 2020, from the coroner for South London. Sent to 2 organisations or people.
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 17 Apr 2020. 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 dated21 Feb 2020
- Deadline17 Apr 2020
- Published on judiciary.uk27 Mar 2020
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Oxleas NHS Foundation TrustNamed in the report as “Oxleas NHS Foundation” | Response publishedPublished on judiciary.uk in February 2020. |
| ADAPT | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 17 Apr 2020. A reply may have been sent and not yet published. |
The coroner’s concerns
– (1) The findings of the internal investigation by Oxleas NHS were that the assessment undertaken by the Community Mental Health Nurse did not illicit sufficient information to enable the multidisciplinary team to properly review Mr Jenkins’ mental health. Despite this the multi-disciplinary team proceeded with a review and decided that he did not have a mental health condition, without seeking a further assessment (2) The Community Mental Health Nurse did not document her formulation or impression. The plan moving forward was not robust and did not explore protective factors or minimisation of harm and there was an over-reliance on alcohol and drug use as the cause of his suicidal ideation. There appeared to be no proforma of questions to ask. (3) As a direct consequence of the limited information gathering Billy Jenkins was not properly assessed and it was not known whether he had a mental health diagnosis which required treatment. (4) It was not known whether as a result of this death there had been any lessons learned by the teams involved in care and treatment of Billy Jenkins, or whether there had been any training or support requirements identified for the Community Mental Health Nurse.
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, 2020-0068
- 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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