“(brief summary of matters of concern) Firstly that the system of high level intermittent…”
Dated 10 Oct 2024, from the coroner for Milton Keynes. 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 5 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 dated10 Oct 2024
- Deadline5 Dec 2024
- Published on judiciary.uk11 Oct 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Central and North West London NHS Foundation TrustNamed in the report as “Central North West 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
(brief summary of matters of concern) Firstly that the system of high level intermittent observations failed to prevent Florence's suicide and needs a fundamental review. Secondly, that the Oxygen bottle used during resuscitation ran out of oxygen. Regulation 28 – After Inquest Document Template Updated 30/07/2021
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, 2024-0539
- Added to Minute Book
- 8 Oct 2026
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- 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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