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Coroner’s reportPrevention of future deaths · 2024-0036

“Following concerned calls by family no advice was provided on what options were available…”

Dated 20 Jan 2024, from the coroner for South Yorkshire West. 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.

Read the full report on judiciary.uk

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The 56-day response deadline

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Replies were due by 16 Mar 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.

  1. Report dated20 Jan 2024
  2. Deadline16 Mar 2024
  3. Published on judiciary.uk25 Jan 2024
  4. Today23 Oct 2026

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Sent toResponse
South West Yorkshire Partnership Teaching NHS Foundation TrustNamed in the report as “South West Yorkshire Partnership Trust”Response publishedPublished on judiciary.uk in January 2024.

The coroner’s concerns

– 1. Following concerned calls by family no advice was provided on what options were available to them if they were concerned for their family members safety and no provision of services that could be called to discuss her mental state. 2. Despite identifying the risk of emotional dysregulation and that BSARCS would mitigate this risk. When IHCBTT were informed BSARC was not available no further consideration was given to any other service to minimise the risk.

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, 2024-0036
Added to Minute Book
8 Oct 2026
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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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