“:(1) No assessment of the risk of suicide or self-harm upon release took place during the…”
Dated 16 Jun 2023, from the coroner for Manchester North. 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 publishedOrganisations 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 dated16 Jun 2023
- Deadline11 Aug 2023
- Published on judiciary.uk18 Oct 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Midlands Partnership University NHS Foundation TrustNamed in the report as “Midlands Partnership NHS Foundation Trust” | Response publishedPublished on judiciary.uk in October 2023. |
The coroner’s concerns
:(1) No assessment of the risk of suicide or self-harm upon release took place during the Deceased's time in detention (2) There was a lack of clear communication to the Police as to what, if any assessment had taken place. (3) The conversation between the Practitioner and the Deceased took place through an observation hatch in circumstances where no risk was posed to the Practitioner from being in the same room as the Deceased. This was not best practice. (4) The terminology used by the Practitioner was misleading in that it suggested that there was no role for the liaison and Diversion service because no unmet needs or vulnerabilities had been identified. The evidence was that the Deceased had declined consent for an assessment of unmet needs and vulnerabilities and therefore the notes should have made clear that an assessment of unmet needs and vulnerabilities had not taken place. (5) The 'review' undertaken by a Health & Justice Operational Manager of the West Mercia Health & Justice Service consisted of duplication of the Practitioners statement with no comment, observations or identification of areas of learning.
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, 2023-0366
- 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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