“Despite the Trust having prepared a detailed report and addendum for my consideration…”
Dated 11 Dec 2023, from the coroner for Plymouth, Torbay and South Devon. Sent to 2 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 5 Feb 2024. 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 dated11 Dec 2023
- Deadline5 Feb 2024
- Published on judiciary.uk19 Dec 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Devon Partnership NHS Trust | Response publishedPublished on judiciary.uk in December 2023. |
| Langdon Hospital | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 5 Feb 2024. A reply may have been sent and not yet published. |
The coroner’s concerns
– Despite the Trust having prepared a detailed report and addendum for my consideration after the inquest I am still concerned about the following : (1) Paul Perrott’s observations charts were not filled out adequately or at all on the date of his death (2) There appeared to be a lack of clarity over who was responsible for checking the observation charts ,when they would be checked by staff over the course of a working day and who would regularly feed back to staff if there was a problem in this respect . (3) At least one member of staff was unaware that Paul had described himself to staff in May 2020 as looking for an opportunity to take his own life if it arose and that Paul had attempted to take his own life less than 3 months previously in exactly the same way as on 31st July 2020. (4 ) Although certain changes to policy and procedures were described to me there still seems to be a focus on risk in the “here and now “which does not include an analysis of historical and contextual risks
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, 2023-0522
- 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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