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Coroner’s reportPrevention of future deaths · 2021-0094

“The application of the CPA policy for patients such as Roy so that they will have a…”

Dated 29 Mar 2021, from the coroner for Buckinghamshire. 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.

Read the full report on judiciary.uk

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The 56-day response deadline

Deadline passed

Replies were due by 24 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.

  1. Report dated29 Mar 2021
  2. Deadline24 May 2021
  3. Published on judiciary.uk13 Apr 2021
  4. Today23 Oct 2026

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Responses from each recipient

Responses from each recipient
Sent toResponse
Oxford Health NHS Foundation TrustResponse 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.

The coroner’s concerns

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— 1. The application of the CPA policy for patients such as Roy so that they will have a detailed care plan with which they can engage and which informs the family, the care coordinator and the community team on discharge from the inpatient setting. Reinforcing the importance of the role of care coordinator and ensuring the timely allocation to inpatients shortly after admission so that they can work over a meaningful period with the patient, the family and the mental health teams in anticipation of the discharge into the community. Coroner’s Office, 29 Windsor End, Beaconsfield, Buckinghamshire. HP9 2JJ C.G.BUTLER SENIOR CORONER + BUCKINGHAMSHIRE

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, 2021-0094
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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