“Miriam was admitted to the mental health unit at approximately 8.30pm”
Dated 20 May 2024, from the coroner for Derby and Derbyshire. 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 15 Jul 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 dated20 May 2024
- Deadline15 Jul 2024
- Published on judiciary.uk23 May 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Derbyshire Healthcare NHS Foundation TrustNamed in the report as “Derbyshire Healthcare NHS Trust” | Response publishedPublished on judiciary.uk in May 2024. |
The coroner’s concerns
Miriam was admitted to the mental health unit at approximately 8.30pm. The unit has a staff handover between 9.00pm and 9.30pm. The evidence at inquest was contradictory as to which shift had assumed responsibility for completing admission tasks including risk assessments and care / safety plans. It was recognised that admission shortly before or during shift handover can increase risks relating to the quality of information sharing and the allocation of admission tasks such as assessing the level of observations required. The court heard evidence that whilst efforts would be made to avoid admission during staff handover time this was a local practice rather than part of any formal policy. The court further heard evidence that senior staff considered that avoidance of admission at handover times would be difficult to achieve because there were too many different oranisations who might be requesting admission. This appeared to overlook the fact that it is the bed allocation team based at the trust who are the central point of contact. The current operational policy covering admission procedures (Acute Inpatient Operational Policy) does not mention a need for handover time to be protected, avoiding admission during this time. Without a formal policy on this topic there is a risk that future deaths could occur.
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, 2024-0277
- Added to Minute Book
- 8 Oct 2026
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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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