“Evidence given by the court appointed expert consultant psychiatrist was that Ms Petit…”
Dated 26 Sep 2024, from the coroner for Surrey. Sent to 2 organisations or people.
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 21 Nov 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 dated26 Sep 2024
- Deadline21 Nov 2024
- Published on judiciary.uk26 Sep 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Surrey and Borders Partnership NHS Foundation TrustNamed in the report as “Surrey and Borders Partnership Trust” | Response publishedPublished on judiciary.uk in September 2024. |
| NHS England | Response publishedPublished on judiciary.uk in September 2024. |
The coroner’s concerns
– (1) Evidence given by the court appointed expert consultant psychiatrist was that Ms Petit was not adequately medicalised and that she needed assessment and medical review with optimisation of treatment in a mental health hospital. Her response to treatment needed to be observed. This is what a s2 admission is designed to effect. The lack of a bed in a mental health hospital denied Ms Petit this opportunity for optimal treatment. (2) The Court heard that owing to a shortage of mental health beds patients who have been assessed by 2 s12 consultant psychiatrists to require detention after a mental health act assessment are being effectively detained in general hospitals without a section, awaiting a bed, because they cannot be placed under section unless a mental health bed is available.
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, 2024-0514
- Added to Minute Book
- 8 Oct 2026
- Reuse
- 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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