“The ongoing failure of SPFT to require their staff to comply with the Trusts therapeutic…”
Dated 15 Jul 2021, from the coroner for Brighton and Hove. 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
All responses publishedReplies were due by 9 Sep 2021.
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; a reply may have been sent and not yet published.
- Report dated15 Jul 2021
- Deadline9 Sep 2021
- Published on judiciary.uk3 Aug 2021
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Sussex Partnership NHS Foundation TrustNamed in the report as “Sussex Partnership Foundation NHS Trust” | Response publishedPublished on judiciary.uk in August 2021. |
The coroner’s concerns
(1) The ongoing failure of SPFT to require their staff to comply with the Trusts therapeutic engagement and observation policy. Especially those sections which relate to night times or when patients are believed to be sleeping (see para 4.5.5, 4.5.7 and table 1 -page 5). Since 27.12.2019 to 5.3.2021 there have 1 VERONICA HAMILTON-DEELEY DL, LL.B. Her Majesty's Senior Coroner for the City of Brighton & Hove THE CORONER'S OFFICE WOODYALE, LEWES ROAD BRIGHTON BN23QB been three occasions when patients described as asleep over a series of observations, have actually been found to have been dead for several hours. Serious Incident reports have promised action but nothing effective has been produced.
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, 2021-0257
- 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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