“When Mrs Cobain cancelled her appointment scheduled for Monday 6 September 2021 by email…”
Dated 25 Mar 2024, from the coroner for Inner South London. 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 20 May 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 dated25 Mar 2024
- Deadline20 May 2024
- Published on judiciary.uk26 Mar 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| South London and Maudsley NHS Foundation Trust | Response publishedPublished on judiciary.uk in March 2024. |
The coroner’s concerns
1. When Mrs Cobain cancelled her appointment scheduled for Monday 6 September 2021 by email on Saturday 4 September 2021, the system nevertheless generated 2. 3. 4. 5. an automatic questionnaire which is normally is sent 24 hours prior to a scheduled assessment appointment. The system had not recognised that Mrs Cobain had cancelled her appointment. She completed the questionnaire. Mrs Cobain’s responses to the questionnaire contained what were accepted to be concerning responses. Due to the cancellation the questionnaire was not reviewed by a clinician until after Mrs Cobain’s sad death. Changes have been made to the protocols around cancellation, and language has been added to the assessment template. However, there is no system or protocol to alert a clinician to review concerning responses and to consider appropriate next steps, where (outside the usual protocol and time frame of submission and review within 24 hours of the assessment appointment) the patient has completed the questionnaire, and for whatever reason, the assessment appointment with the clinician is not for a period of several days/weeks as was the case in Mrs Cobain’s case. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 20 May 2024 I, the coroner, may extend the period.
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, 2024-0163
- 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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