“Individuals who are the subject of detainment under the Mental Health Act are risk…”
Dated 11 Dec 2020, from the coroner for Inner South London. 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 5 Feb 2021.
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 dated11 Dec 2020
- Deadline5 Feb 2021
- Published on judiciary.uk8 Jan 2021
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Oxleas NHS Foundation TrustNamed in the report as “Oxleas NHS Trust” | Response publishedPublished on judiciary.uk in January 2021. |
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) Individuals who are the subject of detainment under the Mental Health Act are risk assessed at numerous times. For those that are on Section 17 home leave, they are additionally assessed prior to leaving the ward on each occasion. In addition, risks are also reviewed on the regular multi-disciplinary ward rounds. (2) However, such assessments are not centralised in any one place – there is no central formulation. Reviews by any clinician would have to cover 3 or 4 different entries by way of example: the risk assessment page, the MDT notes, the psychology entries (although they, per se, do not enter risks assessments). (3) The Court’s expert confirmed that such a centralisation/ formulation (supported by the Route Cause Analysis report), would assist in reviewing an individual’s risk and allowing ward staff to see the wider input in one place. (4) Training has been implemented by the Trust to assist staff in formulating risk, a process that was in place at the time of Claire’s death. However, there is no central repository/formulation of the outcomes of those assessments. Different teams continue to use different tools; there is no stand-alone document. (5) Consideration should therefore be given to the creation of a centralised, formulated, risk document to be entered upon by all clinicians irrespective of their own speciality.
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, 2020-0297
- 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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