“(brief summary of matters of concern) 5 CORONER’S CONCERNS During the course of the…”

The coroner’s concerns

(brief summary of matters of concern) 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters given rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you; the MATTERS OF CONCERN as follows. – Regulation 28 – After Inquest Document Template Updated 30/07/2021 In evidence it was heard that Owen had a limited short-term memory and a cognitive deficit, due to the previous Traumatic Brain Injuries that he had suffered. As a result of Owen’s limited short-term memory and cognitive deficit, it was agreed that his next of kin would be informed of all of the appointments Owen had with the NSFT clinician’s providing his care. Evidence at inquest heard that Owen’s next of kin had been informed of such meetings on some occasions, but that it did not occur on every occasion. In addition, evidence was heard that when meetings were changed a short notice (due to unforeseen circumstances, staff sickness or leave absence), Owen himself would be informed, but not his agreed next of kin contact. This led to Owen missing a number of appointments as he had forgotten the changes made, whereas his next of kin would have been able to remind him, and prompt him to attend. It was acknowledged by the court, that in Owen’s case there was no evidence that his attendance at one of his missed appointments would have changed the tragic outcome. However, I am concerned that in the future, an individual with a short-term memory and a cognitive deficit will miss an appointment which could prevent their death, if their next of kin (or chosen point of contact) are not also told of short notice changes to the timings of that appointment. Evidence was heard that there is no system in place to facilitate this.

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, 2024-0374

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