“(brief summary of matters of concern) Regulation 28 – After Inquest Document Template…”
Dated 10 Jan 2025, 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 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 |
|---|---|
| Oxford Health NHS Foundation Trust | Response publishedPublished on judiciary.uk in January 2025. |
The coroner’s concerns
(brief summary of matters of concern) Regulation 28 – After Inquest Document Template Updated 30/07/2021 None of the records of contact with Mr Raciborski completed by the AMHT in the period from August 2023 to the date of Mr Raciborski’s death contained any written record of a risk assesment. I found that in Mr Raciborski’s case this absence did not impact his treatment and was not a causative factor. However my concern is that the failure to properly record the details of a risk assesment can lead to inadequate information sharing and the possiblity of someone who relies upon the records gaining the wrong impression. In addition it does not allow the adequacy of the risk assesments to be properly investigated and could hinder investigations into deaths; which mean that a matter giving rise to a risk to life may not be identified in future investigations.
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, 2025-0018
- 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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