“Evidence was heard regarding the manner in which information crucial to the formulation…”
Dated 26 Jul 2022, from the coroner for Exeter and Greater Devon. 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 publishedOrganisations 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 dated26 Jul 2022
- Deadline20 Sep 2022
- Published on judiciary.uk29 Sep 2022
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Devon Partnership NHS Trust | Response publishedPublished on judiciary.uk in September 2022. |
The coroner’s concerns
– 1.Evidence was heard regarding the manner in which information crucial to the formulation of risk assessments was recorded and shared: a)Two types of risk assessments were completed, with no system to ensure that important information is present on both; b) The previous incident in which Archi had attempted to take his own life in very similar circumstances on the ward was not clearly entered on the risk assessments used by staff and therefore not known to a number of those responsible for his care; c) Those responsible for his care accepted that the above incident was one of which they would have wanted to have knowledge; d) The absence of that information may have affected the subsequent decisions made regarding the setting of risk level, observation level and removal of potentially dangerous ligature items.
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, 2022-0231
- 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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