“The Coroner has seen a copy of the Root Cause Analysis dated 27 March 2020”
Dated 23 Oct 2020, from the coroner for Plymouth, Torbay and South Devon. 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 18 Dec 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 dated23 Oct 2020
- Deadline18 Dec 2020
- Published on judiciary.uk4 Dec 2020
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Devon Partnership NHS Trust | Response publishedPublished on judiciary.uk in June 2022. |
The coroner’s concerns
(1) The Coroner has seen a copy of the Root Cause Analysis dated 27 March 2020. Your reference number RMS: author(2) At Page 20 of the Root Cause Analysis there is an outcome of the review listed under Immediate Changes - Ensure risk assessments are completed for patients going on leave, which identify risks in the community and agreed actions to be taken by staff in case of a breakdown in plan Sharing the learning - To be shared with Ward Staff and Community Teams
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, 2020-0214
- 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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