“. 1”
Dated 15 Feb 2022, from the coroner for East London. Sent to 3 organisations or people.
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 12 Apr 2022. 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 dated15 Feb 2022
- Deadline12 Apr 2022
- Published on judiciary.uk21 Feb 2022
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Department of Health and Social Care | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 12 Apr 2022. A reply may have been sent and not yet published. |
| East London NHS Foundation TrustNamed in the report as “East London Foundation NHS Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 12 Apr 2022. A reply may have been sent and not yet published. |
| NHS England | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 12 Apr 2022. A reply may have been sent and not yet published. |
The coroner’s concerns
. 1. Expert psychiatric evidence indicated that Mr Lennon was a suitable candidate for the Care Programme Approach mental health pathway and that the use of this pathway would have reduced the risk of an acute deterioration in his mental state . The CRT failed to effectively monitor whether Mr Lennon was on a care pathway appropriate to his needs. 2. The CRT undertook a flawed review of Mr Lennon's mental state on 29/7/19 which failed to assess that, Jason was in relapse and was a risk of harm to himself and others. Factors which contributed to this failure included ; a. b. c. 6 CRT staff did not effectively review medical records prior to assessing Jason, The CRT did not communicate important clinical information between themselves and external stakeholders, The CRT did not adequately document important information arising from the assessment. 3. The Trust undertook a serious incident investigation report into the events leading to Mr Lennon's death in November 2019 which made a series of recommendations for action . The action plan was found to have been incomplete by 6/2/22 due to errors attributable to the Trust's governance team . 4. Accepted individual failings by staff within the CRT fall below standards set by their regulator. There is no evidence before the court to assess whether ELFT have considered the necessity to make a referral to a regulator.
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, 2022-0048
- 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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