“CNWL - All staff who would be expected to refer cases to healthcare need as much…”
Dated 6 Jul 2020, from the coroner for West 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
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 dated6 Jul 2020
- Deadline31 Aug 2020
- Published on judiciary.uk9 Oct 2020
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Central and North West London NHS Foundation TrustNamed in the report as “Central & North West London NHS Foundation Trust” | Response publishedPublished on judiciary.uk in June 2022. |
| Independent Monitoring Board | Response publishedPublished on judiciary.uk in June 2022. |
The coroner’s concerns
– 1. CNWL - All staff who would be expected to refer cases to healthcare need as much assistance as possible in order to discharge that responsibility effectively. It is recognised CNWL is the new healthcare provider and did not provide healthcare in 2012. It is also recognised that CNWL have improved the training on how to make a referral. However, there was knowledge on how to make a referral in 2012 and the jury have highlighted the failures that still occurred, leading to the death of Mr Fosu . My concern centres on improving the recognition of when to make a referral as opposed to knowing the mechanics of making a referral once a decision has been made to refer. By way of respectful analogy, medical practitioners referring cases to a coroner know how to make a referral but now have guidance in legislation as to when to refer. The Trust should give serious consideration to developing a guide to all staff on when to refer cases to healthcare. This should be achievable without being either overprescriptive or over-restrictive. 2. IMB- The current practise remains to refer concerns around detainees only to the Home Office contract monitor. I see no good reason not to, in addition and simultaneously, report concerns to the healthcare managers at the IRC. In recording this concern I have in mind the jury’s determinations and findings in the record of inquest which highlight ineffective joint working across all agencies. Simultaneous reporting of issues would lessen the prospect of a healthcare related issue slipping through the net and not being addressed.
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, 2020-0148
- 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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