“Expert evidence was heard (and accepted) at inquest that there was no written…”
Dated 31 Dec 2021, from the coroner for Lancashire and Blackburn with Darwen. 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 25 Feb 2022.
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 dated31 Dec 2021
- Deadline25 Feb 2022
- Published on judiciary.uk10 Jan 2022
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Lancashire & South Cumbria NHS Foundation TrustNamed in the report as “Lancashire and South Cumbria NHS Foundation Trust” | Response publishedPublished on judiciary.uk in January 2022. |
The coroner’s concerns
– Expert evidence was heard (and accepted) at inquest that there was no written policy/document in place by the Trust which set out :(1) The circumstances in which group leave from the Cove ( and other tier 4 units) is granted and who is responsible for the granting of such leave. (2) That a mandatory risk assessment is required and setting out a list of f actors/criteria that must be considered before any group leave is granted. (3) Setting out the staff to patient ratios for any group leave and identifying the criteria to be considered.
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, 2022-0005
- 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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