“(brief summary of matters of concern) At inquest, Matthew's mother gave evidence that she…”

The coroner’s concerns

(brief summary of matters of concern) At inquest, Matthew's mother gave evidence that she was never informed of the terms upon which Matthew's section 17 leave had been authorised by those responsible for his treatment and specifically that Matthew should never be left alone or unaccompanied whilst on section 17 leave nor was she provided with a copy of Matthew's section 17 leave form. The Trust acknowledged and admitted that there was no evidence in any records available to it that such discussions had been had with Matthew's mother or that a copy of the section 17 leave form had been provided to her. The Trust gave evidence of changes implemented since Matthew's tragic death to avoid future recurrence and I requested additional evidence from the Trust in relation to audited compliance data. Notwithstanding changes already implemented and envisaged and by its own admission, the Trust's compliance data is "inconsistent" generally but specifically in relation to the provision of the section 17 leave form to a carer/ person accompanying a patient subject to section 17 leave. That evidence demonstrated a 50% compliance rate in December 2023, a 52% compliance rate in March 2024 and a 76% compliance rate in May 2024, with a compliance rate of 80% or above considered to be "good" by reference to the Trust's compliance criteria. Additionally and in relation to changes already implemented, the Trust's evidence at inquest was that its revised section 17 leave policy for detained patients had removed the previous requirement that the section 17 leave form ought tot be signed by the person accompanying the patient, the explanation for this being the Trust's roll-out of a new digitised system. The inconsistent compliance audit data referenced above gives rise to a concern that there is risk that future deaths could occur consequent to this change unless action is taken.

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, 2024-0456

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