“Regulation 28 – After Inquest Template Updated 15/10//2024 TG Whilst I heard evidence…”
Dated 10 Jan 2025, from the coroner for West Sussex, Brighton and Hove. 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 7 Mar 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 dated10 Jan 2025
- Deadline7 Mar 2025
- Published on judiciary.uk13 Jan 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| University Hospitals Sussex NHS Foundation Trust | Response publishedPublished on judiciary.uk in January 2025. |
The coroner’s concerns
Regulation 28 – After Inquest Template Updated 15/10//2024 TG Whilst I heard evidence that the UHS Foundation Trust has a Missing Person policy – Walkouts/absconding patients (approved 23 May 2024), in Mr Summersett’s case there was a lack of recorded and/or shared information across all the agencies and teams with whom he had had contact, or to whom he was known, such that an accurate and fully reflective risk assessment was not achieved, exacerbated by delays in the triage process in the ED. Mr Summersett was not notified to Police as a missing person and nor were Police informed he had left the ED, despite them simultaneously raising a safeguarding risk via a Vulnerable Adult Single Combined Assessment of Risk Form. In sum, there was therefore a lack of information sufficiency, flow and sharing across the agencies whilst he was present in, and at and after the point he left, the ED, which might have enabled greater efforts to locate, contact and more urgently treat him.
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, 2025-0015
- 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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