“I was concerned to find that even though 5 years had elapsed between Kay’s death and the…”
Dated 28 Mar 2021, from the coroner for West London. 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 23 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 dated28 Mar 2021
- Deadline23 May 2021
- Published on judiciary.uk13 Apr 2021
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Central and North West London NHS Foundation Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 23 May 2021. A reply may have been sent and not yet published. |
| NHS England | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 23 May 2021. A reply may have been sent and not yet published. |
The coroner’s concerns
– (1) I was concerned to find that even though 5 years had elapsed between Kay’s death and the hearing of the Inquest the issue of the way in which the Care Programme Approach was being conducted between the local authority and the NHS Trust was still the subject of discussion and had not been resolved to the satisfaction of the manager responsible for the process. The delay in my view represents a threat to the lives of others in similar situations. (2) I was concerned by evidence in the course of the Inquest that the disengagement of a person with known psychological illness from the process of registration with a GP by her failure to obtain relevant documentary proof to enable registration meant that she could not be registered. Registration with a regular GP would in my mind have provided additional support to her. This may have enabled her to raise concerns or fears relating to her accommodation and housemate. 4
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, 2021-0099
- Added to Minute Book
- 8 Oct 2026
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- 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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