“The deceased was accommodated in a Care Home that was subsequently formally closed due to…”
Dated 7 May 2021, from the coroner for Plymouth, Torbay and South Devon. Sent to 3 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 2 Jul 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 dated7 May 2021
- Deadline2 Jul 2021
- Published on judiciary.uk7 May 2021
- Today27 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Care Quality Commission | Response publishedPublished on judiciary.uk in May 2021. |
| Devon Partnership NHS TrustNamed in the report as “Devon Partnership 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. |
| Plymouth Safeguarding Adult Partnership | Response publishedPublished on judiciary.uk in May 2021. |
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) The deceased was accommodated in a Care Home that was subsequently formally closed due to poor service. The selection of the accommodation was made without a physical inspection of its suitability for the deceased by the organisation with responsibility for providing the accommodation before the deceased took up residence.
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, 2021-0142
- 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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