“Both the Local Authority and the Trust were involved in the care of Miss Wells for the…”
Dated 23 Nov 2020, from the coroner for Brighton and Hove. 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 18 Jan 2021. 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 dated23 Nov 2020
- Deadline18 Jan 2021
- Published on judiciary.uk29 Dec 2020
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Sussex Partnership NHS Foundation TrustNamed in the report as “Sussex Partnership Foundation NHS Trust” | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Brighton and Hove City Council | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
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
1. Both the Local Authority and the Trust were involved in the care of Miss Wells for the last 24 hours of her life. Evidence showed that there was a grey area in respect of responsibility for her care, at this time. There was no clear guidance as to who held overall responsibility for her care and there was no clear policy of how the two organisations should work together in these kinds of situations. It is requested that the Local Authority and the Trust consider how to improve communication and clearly define responsibility between the two organisations which could improve the safety of patients with serious mental health difficulties who were waiting for urgent admission to a mental health unit. 2. In this case a clinical decision was made to leave Miss Wells at home until a bed was found with Miss Wells, who was already ill enough to need urgent admission, having to inform the services if she declined further. No provision was made for Miss Wells to be reviewed out of hours, overnight and into the early morning by, for example the Crisis Team, and no advice offered on the existence of a place of safety at the local Mental Health Hospital. Evidence showed that professionals can contact the Crisis Team in these circumstances but that is not done as a routine and patients appear to be left to make important decisions for themselves in circumstances where their declining mental health may prohibit them from doing so. It is requested that the Trust consider ways of providing extra support and supervision to those patients who are waiting for an urgent admission, particularly those who may be left alone at home for any period until a bed is found.
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, 2020-0248
- 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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