“Ms”
No date on the report, from the coroner for Avon. 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
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Responses from each recipient
| Sent to | Response |
|---|---|
| Avon and Wiltshire Mental Health Partnership NHS TrustNamed in the report as “Avon and Wiltshire Mental Health Trust” | Response publishedPublished on judiciary.uk in November 2022. |
The coroner’s concerns
Ms. Mitchell was under the care of AWP Trust with suicidal ideation from March to May 2022 until she st hung herself on 31 May 2022. Throughout this period she presented regularly and persistently with a) delusions; b) auditory hallucinations (including command); c) visual hallucinations; d) intrusive thoughts of killing her partner and children; e) her and her family requesting admission The Coroner's Cou rt, Old Weston Road, Flax Bourton, BS48 lUL Despite this a) No formal diagnosis was made; b) No escalation in management or admission took place. The Coroner's Court, Old Weston Road, Flax Bourton, 8S48 lUL 6 ACTION SHOULD BE TAl<EN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.
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, 2022-0356
- 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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