“Whilst there was good multi-agency working before Mr Pearson moved into his own…”
Dated 10 Nov 2022, from the coroner for South 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
All responses publishedReplies were due by 5 Jan 2023.
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; a reply may have been sent and not yet published.
- Report dated10 Nov 2022
- Deadline5 Jan 2023
- Published on judiciary.uk11 Nov 2022
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Bromley Council | Response publishedPublished on judiciary.uk in November 2022. |
| Oxleas NHS Foundation Trust | Response publishedPublished on judiciary.uk in November 2022. |
| Clarion Housing Group | Response publishedPublished on judiciary.uk in November 2022. |
The coroner’s concerns
– (1) Whilst there was good multi-agency working before Mr Pearson moved into his own accommodation, that was lacking when it became necessary to move him on an emergency basis despite the circumstances increasing his anxiety and vulnerability. Partnership working and sharing of information between the authorities may help mitigate risk in future cases of emergency decants. (2) In respect of Oxleas NHS Foundation Trust, a referral was made by Mr Pearson’s GP 1 to the ADAPT service but at the time there was a 2-3 backlog in screening referrals and the GP was not made aware of the capacity issues. A robust contingency plan would ensure that referrers are informed when services are not able to meet usual service expectations. I heard evidence of openness to remedy these matters, which is welcome, but plans were at a very early stage by the date of the inquest.
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, 2022-0358
- Added to Minute Book
- 8 Oct 2026
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- 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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