“At the inquest I was referred to the National Confidential Enquiry into Suicides”
Dated 30 Jun 2023, from the coroner for Gwent. 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 25 Aug 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 dated30 Jun 2023
- Deadline25 Aug 2023
- Published on judiciary.uk7 Jul 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Aneurin Bevan University Health Board | Response publishedPublished on judiciary.uk in July 2023. |
The coroner’s concerns
At the inquest I was referred to the National Confidential Enquiry into Suicides. I was informed that the Enquiry identified key factors that should be adopted by Health Organisations to reduce the incidence of suicides, including: That there should be a strategy for engagement with the family. That every patient should have access to 24-hour Crisis Support Neither of these key components of care were available to Kaye. Whilst I was informed that there were steps being taken to address these I was not persuaded that these guidelines had been fully inculcated into policy and practice at Aneurin Bevan University Health Board.
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, 2023-0221
- 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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