“During the inquest there was evidence that Working with Risk (WWR) documentation was not…”

The coroner’s concerns

i. During the inquest there was evidence that Working with Risk (WWR) documentation was not completed on approximately the first nine contacts with Mr Hammond. The 1st contact was on 23rd December 2020 where 2 hours had been allocated for this task as well as the initial assessment and care plan – none of the written documents were completed. The WWR documents were also not completed (on subsequent contacts) on 31/12/20, 3/01/21, 4/01/21,5/01/21, 6/01/21, 7/01/21, 8/01/21, 10/01/21 and 11/01/21. The Trust was unable to give an explanation for these failures. As a result, the care plan for Mr Hammond was unsatisfactory. 6. ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action. 7. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 31st January 2022. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8. COPIES and PUBLICATION I have sent a copy of my report to the following: 1. HHJ Teague QC the Chief Coroner of England & Wales Chief Coroner's Office, 11th Floor Thomas More, Royal Courts of Justice, Strand, London, WC2A 2LL. chiefcoronersoffice@judiciary.gsi.gov.uk 2. Mr Hammond’s family – via I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response. Date: 6th December 2021

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, 2021-0409

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8 Oct 2026

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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