“Mr”
Dated 15 Mar 2021, from the coroner for Brighton and Hove. 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
Deadline passedReplies were due by 10 May 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 dated15 Mar 2021
- Deadline10 May 2021
- Published on judiciary.uk23 Mar 2021
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Sussex Partnership NHS Foundation Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 10 May 2021. A reply may have been sent and not yet published. |
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— (1) Mr. Steele was lost to ATS follow up apparently due to inefficient processes and a failure to appreciate the urgent need to appoint a Lead Practitioner for him. In particular the focus and delivery of the Care Programme Approach (CPA) as set out in national guidance “Refocusing the CPA- Policy and Positive Practical Guidance” does not appear to have been followed. (2) In addition Sussex Partnership Foundation Trust appears to take a fragmented approach to its policies. Business is conducted in one way in Brighton and in another way, for example, in East or West Sussex and yet patients could be in Sussex depending on availability. They would apparently be dealt with differently depending on their geographic location. At Tim Steele’s Inquest it was clear that staff members were not aware o how matters would be dealt with in other parts of Sussex. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you AND your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 5 June 2021. |, the Coroner may extend the period.
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, 2021-0076
- 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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