“as follows”
Dated 6 Apr 2020, from the coroner for Suffolk. 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 1 Jun 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 dated6 Apr 2020
- Deadline1 Jun 2020
- Published on judiciary.uk20 Apr 2020
- 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 |
|---|---|
| Adult and Community Services Suffolk County Council | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 1 Jun 2020. A reply may have been sent and not yet published. |
| Norfolk and Suffolk NHS Foundation Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 1 Jun 2020. A reply may have been sent and not yet published. |
The coroner’s concerns
as follows. – In Darren’s case it was clear that due to his learning disability and autism, engagement with him could be difficult. However, the following three areas of concern were identified. 1. The lack of effective follow up action when a patient with learning disabilities disengages, especially when they are a high-risk patient (such as Darren). 2. The lack of a clear escalation process when an increased risk is identified and this risk cannot be easily addressed (as it was in Darren’s case). 3. The lack of a structured medication review as part of the overall Care Plan Approach so that staff from all agencies involved are aware of the importance of medication compliance and understand the referral/escalation routes should they have a concern.
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, 2020-0090
- 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