“. A clear risk was raised at the CPA meeting on the 4th December 2018”
Dated 28 Sep 2022, from the coroner for East London. 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
Deadline passedReplies were due by 23 Nov 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 dated28 Sep 2022
- Deadline23 Nov 2022
- Published on judiciary.uk7 Oct 2022
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| East London NHS Foundation TrustNamed in the report as “East London Foundation Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 23 Nov 2022. A reply may have been sent and not yet published. |
The coroner’s concerns
. A clear risk was raised at the CPA meeting on the 4th December 2018. This was the risk of Donna taking medications prescribed to her husband . This risk was not documented in the Trust's mental health records , not fully assessed and no risk management plan was put in place to protect Donna from harm . The absence of a risk assessment and management plan was not identified as a failing within the Trust's internal investigation report and no steps have been taken by the Trust to improve the systems in place.
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, 2022-0299
- 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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