“That SPA contacts are not routinely discussed with a supervising clinician, ss should…”
Dated 14 Mar 2023, from the coroner for Inner West 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 9 May 2023. 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 dated14 Mar 2023
- Deadline9 May 2023
- Published on judiciary.uk22 Mar 2023
- Today23 Oct 2026
Watch this report
We’ll email you when a response is published on judiciary.uk, or when the 56 days to reply end with none published there yet. Free, and you can stop with one click.
Responses from each recipient
| Sent to | Response |
|---|---|
| Central and North West London NHS Foundation Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 9 May 2023. A reply may have been sent and not yet published. |
The coroner’s concerns
1. That SPA contacts are not routinely discussed with a supervising clinician, ss should have but did not happen in Ms Norman's case, where mental health symptoms and especially where suicidality is raised by the caller. 2. That such calls are not routinely passed on to a suitably qualified clinician able to undertake mental health assessment and assess risk for the patient. 3. That SPA contacts are not routinely notified to the patient's GP and any mental health services providing care for the patient.
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, 2023-0097
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
Something wrong, such as a date or who it was sent to? Report a mistake
Is this report about someone close to you? You can ask us to remove names from our pages.
Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
Ask about this report
AISummaries and questions, with page references. Pro and above.
Sign in to use