“The medical record documentation for Mr Agius had significant omissions that included an…”
Dated 7 Oct 2024, from the coroner for Essex. 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
Deadline passedReplies were due by 2 Dec 2024. A reply may have been sent and not yet published.
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.
- Report dated7 Oct 2024
- Deadline2 Dec 2024
- Published on judiciary.uk8 Oct 2024
- Today22 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| North East London NHS Foundation Trust | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
The coroner’s concerns
– 1. The medical record documentation for Mr Agius had significant omissions that included an incomplete risk assessment in February 2022 for Mr Agius following his transfer following crisis intervention with the Home Treat Team to avoid an admission to hospital when Mr Agius attempted to take his own life. 1 2. The evidence of assessments of Mr Agius’s mental state provided to the inquest indicated a difference of opinion as to whether Mr Agius was displaying hypermanic symptoms on 12 and 13 February 2022. 3. Evidence was heard that there is new national training for assessing risk for patients with mental health concerns but there was no evidence that the Trust has implemented this training.
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, 2024-0535
- 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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