“The inquest heard that independent doctors did not have access to the CareNotes and…”
Dated 21 Dec 2023, from the coroner for Exeter and Greater Devon. 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 15 Feb 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 dated21 Dec 2023
- Deadline15 Feb 2024
- Published on judiciary.uk29 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. |
The coroner’s concerns
(1) The inquest heard that independent doctors did not have access to the CareNotes and relied upon printed copies of extracts from the notes which the AMHP considered pertinent to the Mental Health Act Assessment. Training is now available for independent s.12 doctors which, once completed, allows them access to CareNotes, but this training is not a mandated condition of their inclusion on the list of approved s.12 doctors. There remains a risk that, should a Trust doctor not be available to conduct the assessment, an independent doctor with no access to the patient’s records would be called upon to conduct an assessment. (2) Several witnesses illustrated a lack of understanding of the concept of both a voluntary admission where a patient has undergone a Mental Health Act Assessment and of the ‘least restrictive option’. The opportunity for a patient to be admitted voluntarily for further assessment and treatment may therefore be missed.
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, 2023-0545
- Added to Minute Book
- 8 Oct 2026
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- 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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