“There were errors in the completion of the hospital's safeguarding questions”
Dated 2 May 2024, from the coroner for Cumbria. 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 27 Jun 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 dated2 May 2024
- Deadline27 Jun 2024
- Published on judiciary.uk14 May 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| North Cumbria Integrated Care NHS Foundation TrustNamed in the report as “North Cumbria Integrated Care” | Response publishedPublished on judiciary.uk in May 2024. |
The coroner’s concerns
– (1) There were errors in the completion of the hospital's safeguarding questions. The clinician answered 'no' to the question 'Is there a safeguarding concern?'. The clinician's evidence was that, in fact, she did have a safeguarding concern and explored it with Ms Thomason, but that she completed the electronic form in error. I am concerned that the 5 form is regarded as a 'tick box' exercise rather than a vital safeguarding tool. (2) There is evidence that Cumbria Housing staff had asked to be notified of the discharge of a vulnerable patient so that they could provide support to her but that they received no communications on several occasions. I am concerned that this may mean that other patients are discharged without appropriate support being alerted to their needs. (3)The evidence I received places an emphasis on the fact that Ms Thomason had capacity and indicated that she felt safe. It is certainly correct that this meant that there could be no question of her being held in hospital. It is also correct that her view of her situation was of relevance. However, it does not mean that obvious vulnerability or safeguarding concerns could not be addressed. Regardless of what Ms Thomason said, her vulnerability was obvious. I am concerned that the concepts of 'having capacity' and 'not being vulnerable' are being elided.
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, 2024-0244
- Added to Minute Book
- 8 Oct 2026
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- 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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