“The Trust’s own internal investigation highlighted the fact that no care coordinator or…”
Dated 25 Nov 2024, from the coroner for Berkshire. 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 20 Jan 2025.
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 dated25 Nov 2024
- Deadline20 Jan 2025
- Published on judiciary.uk27 Nov 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Oxford Health NHS Foundation Trust | Response publishedPublished on judiciary.uk in November 2024. |
The coroner’s concerns
1. The Trust’s own internal investigation highlighted the fact that no care coordinator or key worker was provided to Jai after her discharge from hospital on 7th of September 2022. The Trust’s initial plan was to review this by June 2024, and the aim now is for January 2025, almost two years from Jai’s death. 2. It is still not possible for teams using RiO and the BTT systems to access each other’s clinical notes.
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, 2024-0645
- 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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