“. The MATTERS OF CONCERN are as follows: 1”
Dated 25 Mar 2024, from the coroner for Norfolk. 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
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.uk3 Apr 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Norfolk and Suffolk NHS Foundation Trust | Response publishedPublished on judiciary.uk in April 2024. |
| Department of Health and Social Care | Response publishedPublished on judiciary.uk in April 2024. |
The coroner’s concerns
. The MATTERS OF CONCERN are as follows: 1. Despite additional face to face training being made available to the CRHTT, witness evidence was heard which does not reflect the findings of the investigation and does not recognise the need for a full and proper assessment and the need not to accept a service user’s response to questions raised. 2. There remains a lack of understanding amongst the CRHTT with regard to the scope and limitations of other services available within the community team. 3. There remains a lack of understanding with regard to assessing a person’s mental capacity to make decisions and to fully and properly record the rationale for making decisions. 4. Support provided by FACT is usually carried out by telephone and will in some circumstances not be sufficient to recognise ongoing concerns, for instance with regard to medication concordance. 5. Important emails were not circulated to relevant personnel within the CRHTT. The evidence remains unclear what happened to the emails and why they did not reach the appropriate member of the team. 6. A person can be identified at triage risk assessment as being in need of an “immediate response, within 4 hours” but an assessment is then arranged for within a 24-hour period. 7. Evidence was heard of a nationwide shortage of inpatient mental health beds. Action has been taken by NSFT in an effort to minimise impact, but this does remain an ongoing concern. Regulation 28 – After Inquest Document Template Updated 30/07/2021
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, 2024-0167
- 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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