“Despite there being a safeguarding meeting following Mr”
Dated 28 Feb 2024, from the coroner for Plymouth 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 24 Apr 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 dated28 Feb 2024
- Deadline24 Apr 2024
- Published on judiciary.uk6 Mar 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Torbay and South Devon NHS Foundation TrustNamed in the report as “Torbay and South Devon NHS Trust” | Response publishedPublished on judiciary.uk in March 2024. |
| The Disclosure and Barring Service | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 24 Apr 2024. A reply may have been sent and not yet published. |
The coroner’s concerns
– (1) Despite there being a safeguarding meeting following Mr. Green’s death on 22nd January 2022 there appeared to be no review of whether the local authority ought to be have had policies in place to ensure that independent providers were adequately carrying out their contractual duties towards vulnerable individuals especially if the CQC were correct and there was no role for them in this case (2) gave evidence to the inquest that she believed that there was a role for the CQC here as she believed that Mr Green had been in receipt of a personal care package 6 (3) made a referral to the Disclosure and Barring service in respect of the former manager’s actions and received no response as to what action if any the service were taking or an acknowledgement of her concerns .
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, 2024-0113
- 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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