“Evidence was heard that: (1) There was no clear care plan in place following an emergency…”
Dated 10 Feb 2021, from the coroner for Oxfordshire. 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
Report put online after its 56 daysOrganisations 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; a reply may have been sent and not yet published.
judiciary.uk put this report online on 27 May 2021, after the 56 days for replies had ended (7 Apr 2021). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated10 Feb 2021
- Deadline7 Apr 2021
- Published on judiciary.uk27 May 2021
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Oxford Health NHS Foundation TrustNamed in the report as “Oxford Health NHS 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. |
The coroner’s concerns
– Evidence was heard that: (1) There was no clear care plan in place following an emergency review of Mrs Thompson on 13th March 2020 (2) The care plans and risk assessments at the mental health Trust were not updated: (a) with material information on the facts and circumstances of Mrs Thompson’s overdoses of her medication. (b) the two most recent overdoses were not recorded (c) with further information disclosed by the doctor who treated her most recent overdose that Mrs Thompson had lied about the severity of her overdose that it was probably double that which she initially disclosed also that this was her 4th overdose and another could not be ruled out. (d) on 13th March 2020 following a review with the Trust Consultant Psychiatrist (e) on 13th March 2020 when there was a telephone conversation between Mrs Thompson and her care co-ordinator
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, 2021-0171
- 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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