“Ellis’s Safety Plan did not set out: a”
Dated 11 Jul 2021, from the coroner for Mid Kent and Medway. 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
Deadline passedReplies were due by 5 Sep 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 dated11 Jul 2021
- Deadline5 Sep 2021
- Published on judiciary.uk15 Jul 2021
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| North East London 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. |
The coroner’s concerns
– (1) Ellis’s Safety Plan did not set out: a. the responsibilities of the Child & Adolescent Mental Health Team b. did not contain a contingency plan should Ellis agree to go to Accident & Emergency (2) On 30th September 2020 there was a deviation from the agreed Safety Plan without an updated risk assessment. (3) Not all relevant information was shared between the Child & Adult Mental Health Team about the circumstances disclosed of events on the night of 29th September of Ellis’s failed attempt at hanging as part of a risk assessment. (4) Ellis was found to be in need of a Mental Health Act assessment. Management advice was sought about risk and what action should be taken should Ellis refuse to go to hospital, the advice was contact the police. This advice did not take into account that Ellis had a history of absconding and that he could not be prevented leaving the centre. 2
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, 2021-0237
- 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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