“Following Juliette's death, a Structured Judgement Review ("SJR") was carried out which…”

The coroner’s concerns

– 1. Following Juliette's death, a Structured Judgement Review ("SJR") was carried out which identified steps that have been taken. However, the SJR confirmed that a review of Rio records was being undertaken of those who have not been seen in over 12 months with actions to be identified, and that clinical stratification of current caseload is ongoing. I understand that a review or audit of this process is being scheduled to take place at some point in October 2024 (date unknown). 2. Upon conclusion of the inquest, I am Functus Officio meaning that my powers cease and I will have no way of checking if the recommended actions have been completed. In the circumstances, where action to be taken is outstanding and when a specific review date has not been scheduled, I am concerned that there is a risk of future deaths occurring. 3. The deadline for a response under this Report should coincide with the Trust's planned review/audit in October, therefore I am hopeful that the Trust will be able to respond swiftly thereafter, and hopefully will be able to confirm that positive action that has been taken and whether any further work is necessary.

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, 2024-0459

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