“(brief summary of matters of concern) During a Mental Health triage with the the Mental…”
Dated 22 Feb 2024, from the coroner for Staffordshire and Stoke-on-Trent. 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 18 Apr 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 dated22 Feb 2024
- Deadline18 Apr 2024
- Published on judiciary.uk26 Feb 2024
- Today23 Oct 2026
Watch this report
We’ll email you when a response is published on judiciary.uk, or when the 56 days to reply end with none published there yet. Free, and you can stop with one click.
Responses from each recipient
| Sent to | Response |
|---|---|
| Midlands Partnership University NHS Foundation TrustNamed in the report as “Midlands Partnership Foundation Trust” | Response publishedPublished on judiciary.uk in February 2024. |
The coroner’s concerns
(brief summary of matters of concern) During a Mental Health triage with the the Mental Health and Social Inclusion Hub on 8th February 2023 there was a failure to complete the Risk Assessment in relation to his risk of suicide. When referred to and assessed by the Integrated Mental health Team on 3rd March 2023 again there was a failure to complete a Risk Assessment as to his risk of suicide. Furthermore, in an appointment on 3rd March 2023 1. Suicidal/self-harm thoughts not explored in detail. 2. There was no exploration of his statement to the effect he was actively researching methods of taking his own life. Regulation 28 – After Inquest Document Template Updated 30/07/2021 3. There was no exploration regarding efficacy/concordance with medication. 4. There was no discussion around distraction techniques, coping mechanisms or information about contact details for other services. 5. There was no discussion regarding his support network, next of kin etc. 6. There was no indication of next steps, timescales or when he could expect to be informed of the onward plan and no definite date when his case would be discussed with the Multi Disciplinary Team. On hearing evidence of the investigation into the Mental Health care which he received, beyond offering further training and support to nursing staff and mental health professionals, no assurance could be given of a system change to ensure that such Risk Assessments were completed or that appropriate and adequate exploration is made of matters which may affect how the risk of suicide is managed.
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, 2024-0101
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
Something wrong, such as a date or who it was sent to? Report a mistake
Is this report about someone close to you? You can ask us to remove names from our pages.
Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
Ask about this report
AISummaries and questions, with page references. Pro and above.
Sign in to use