“I did not have a sufficient level of confidence about: Civic Centre, Burdon Road…”
Dated 19 May 2021, from the coroner for Sunderland. 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 14 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 dated19 May 2021
- Deadline14 Jul 2021
- Published on judiciary.uk24 May 2021
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Cumbria, Northumberland, Tyne and Wear NHS Foundation 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. |
| Department of Health and Social CareNamed in the report as “Department for Health and Social Care” | Response publishedPublished on judiciary.uk in May 2021. |
The coroner’s concerns
– I did not have a sufficient level of confidence about: Civic Centre, Burdon Road, Sunderland, SR2 7DN Tel 0191 5617843 | Fax 0191 5537803 | DX 60729 Sunderland www.sunderlandcoroner.co.uk • the provision of a multidisciplinary team of professionals with suitable skills, qualifications and competencies commensurate with their role and the specialty of dementia care; • a prevention model and approach for dementia care that proactively uses detailed assessment, intervention and evaluation of changing care, needs and risks of the individual in order to provide therapeutic interventions and reduce the need for medication; • the evidence of assessments or the application of assessments of the impact of a person’s difficulties, including cognitive and neurological difficulties, polypharmacy, psychological and personality, mental and physical health, social, environmental and care practices, emotions, belief and thoughts of the person; • a continuous engagement with the family in the “triangle of care”, including regular communication and updating life stories; • a focus on the person, asserting absolute value of the person, an individualised approach, while understanding the world from the person’s perspective and provision of a social environment that supports psychological and physical needs; • converting policy into practice. The Trust had done a lot of work since the death of Mr Burgess, and I should also be pleased to hear from the Secretary of State about wider learning for other Trusts.
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, 2021-0163
- 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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