“Mr Lockwood’s re-admission to hospital was indicated as early as 2 February 2023…”
Dated 27 Nov 2023, from the coroner for Inner North 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 22 Jan 2024.
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 dated27 Nov 2023
- Deadline22 Jan 2024
- Published on judiciary.uk6 Dec 2023
- Today27 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Oxleas NHS Foundation Trust | Response publishedPublished on judiciary.uk in December 2023. |
The coroner’s concerns
(1) Mr Lockwood’s re-admission to hospital was indicated as early as 2 February 2023; however, he was not re-admitted to hospital, informally or otherwise. (2) A verbal referral was made for Mr Whitelaw to be urgently reviewed by a psychiatrist following the appointment on 2 February 2023, but not acted on. (3) The Oxleas NHS Foundation Trust’s Serious Incident Investigation Report, dated 8 September 2023, identified numerous matters and learning points, including, but not limited to the following: • There had been a lack of “professional curiosity” in the assessment and planning of Mr Whitelaw’s care and treatment • “Discussions and assessments of risk should be clearly documented” • “Risk formulations should consider both current and historic/contextual risks and incorporate ratings of mood to ensure that these are not used in isolation and are linked with appropriate interventions” • There were “missed opportunities identified in relation to LW’s self-reported deterioration following his discharge from hospital which do not appear to have been fully explored.” However, the Serious Incident Investigation Report does include any plan to address the concerns it identified. As such, there insufficient reassurance that there is plan to address the matters in a meaningful way moving forward.
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, 2023-0486
- 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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