“A concern arose at the Inquest hearing in relation to the absence of liaison between the…”
Dated 26 May 2023, from the coroner for East London. Sent to 5 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
Deadline passedReplies were due by 21 Jul 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 dated26 May 2023
- Deadline21 Jul 2023
- Published on judiciary.uk2 Jun 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 |
|---|---|
| South London and Maudsley NHS Foundation TrustNamed in the report as “South London & Maudsley NHS Foundation Trust” | Response publishedPublished on judiciary.uk in June 2023. |
| North East London NHS Foundation TrustNamed in the report as “North East London Foundation Trust” | Response publishedPublished on judiciary.uk in June 2023. |
| Royal College of Psychiatrists | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 21 Jul 2023. A reply may have been sent and not yet published. |
| Department of Health and Social Care | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 21 Jul 2023. A reply may have been sent and not yet published. |
| NHS England and Tatiana Aesthetic Dermatology Clinic | Response publishedPublished on judiciary.uk in June 2023. |
The coroner’s concerns
1. A concern arose at the Inquest hearing in relation to the absence of liaison between the highly specialist services of the CADAT team and the stepdown 2 services provided by NELFT. There was a lack of full information sharing around risk and joint risk assessment/risk management planning on discharge. 2. Both mental health services were aware that Conrad was accessing aesthetic dermatology treatment. There was a concern that neither service adequately highlighted the risks of accessing such treatment to Conrad or attempted to share information with the skin clinic. The inquest heard that patients with BDD should be fully informed of the risks of seeking aesthetic dermatology treatment and wherever possible, clinics who are providing treatment should be made aware of the BDD diagnosis. 3. The Inquest heard that there is a need for training to be provided to step-down service teams in relation to the diagnosis of BDD and the risks associated with it. 4. The inquest heard that there is a lack of national resources for BDD. The highly specialised service at South London and Maudsley has a very long waiting list (several months). This is on a background of concerns of a likely increase in BDD. In light of this concern, I am also providing this report to the Royal College of Psychiatrists, to the Department for Health & Social Care and to NHSE.
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, 2023-0173
- 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