“Senior nursing staff who gave evidence at the Inquest did not appear to appreciate the…”
Dated 1 Dec 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
All responses publishedReplies were due by 26 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 dated1 Dec 2022
- Deadline26 Jan 2023
- Published on judiciary.uk1 Dec 2022
- Today22 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| North East London NHS Foundation TrustNamed in the report as “North East London Foundation trust” | Response publishedPublished on judiciary.uk in December 2022. |
The coroner’s concerns
1. Senior nursing staff who gave evidence at the Inquest did not appear to appreciate the importance of an agreed comprehensive care plan in which the multi-disciplinary ward team, patient and relatives are involved. The nursing staff did not acknowledge the value of a holistic care plan which incorporates the consideration of the many ways in which patients can be supported to engage in their recovery. Such a care plan could also incorporate assessments of capacity to refuse physical observations. There was no clear evidence of assessment of Mary’s capacity to refuse physical observations. 2. A number of nurses failed to recognise the acute clinical severity of Mary’s condition on the morning of the 19th April 2021. They did not respond to her very concerning clinical state with the necessary urgency.
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, 2022-0389
- 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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