“o o o o Concern 1: Section 17 leave conditions may not always be thoroughly reviewed or…”
Dated 4 Nov 2024, from the coroner for Coventry and Warwickshire. 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
All responses publishedReplies were due by 30 Dec 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 dated4 Nov 2024
- Deadline30 Dec 2024
- Published on judiciary.uk5 Nov 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Coventry and Warwickshire Partnership NHS TrustNamed in the report as “Coventry and Warwickshire Partnership Trust” | Response publishedPublished on judiciary.uk in November 2024. |
The coroner’s concerns
o o o o Concern 1: Section 17 leave conditions may not always be thoroughly reviewed or clarified before a service user is signed out for leave. This lack of verification can lead to unaddressed discrepancies, which may impact the safety and appropriateness of unescorted leave. Concern 2: There may be a lack of accessible or reliable means for service users on unescorted leave to contact the facility if they encounter difficulties. This could impact their ability to seek support or assistance when needed. Concern 3: There may be limitations in the reporting system’s ability to identify and address substantive issues that directly impact patient safety. If critical concerns are overlooked, there is a risk that valuable insights for preventing future incidents may be missed, reducing the system's effectiveness in promoting long-term safety improvements. 6. ACTION SHOULD BE TAKEN: In my opinion, action should be taken to prevent future deaths, and I believe you, have the power to take such action. 7. YOUR RESPONSE: You are under a duty to respond to this report within 56 days of the date of this report, namely by 30 December 2024. I, the coroner, may extend the period if 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, 2024-0597
- 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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