“are, as follows: – 1”
No date on the report, from the coroner for Sunderland. 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
No date on the reportOrganisations 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.
Watch this report
We’ll email you when a response is published on judiciary.uk, or when the 56 days to reply end with none published there yet. Free, and you can stop with one click.
Responses from each recipient
| Sent to | Response |
|---|---|
| Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustNamed in the report as “Chief Executive of Cumbria, Northumberland, Tyne and Wear 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
are, as follows: – 1. The family of the perpetrator were not as engaged by the Trust as much as they could have been in terms of: Office of HM Coroner for the City of Sunderland, City Hall, Plater Way, Sunderland, SR1 3AA Tel 0191 5617843 | Fax 0191 5537803 www.sunderlandcoroner.co.uk ⁃ sharing information with them; and ⁃ acting upon information provided by them. I acknowledge that this must take into account the Service User’s capacity and consent and also respecting confidentiality, but in this case these matters did not seem to be an issue. 2. A more proactive approach may have been appropriate. I am concerned that the opportunities to engage more were not taken.
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, 2022-0141
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
Something wrong, such as a date or who it was sent to? Report a mistake
Is this report about someone close to you? You can ask us to remove names from our pages.
Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
Ask about this report
AISummaries and questions, with page references. Pro and above.
Sign in to use