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Coroner’s reportPrevention of future deaths · 2025-0054

“The assessment from Talking Therapies on 20 November 2023 identified current escalating…”

Dated 30 Jan 2025, from the coroner for Northamptonshire. 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.

Read the full report on judiciary.uk

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The 56-day response deadline

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Replies were due by 27 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.

  1. Report dated30 Jan 2025
  2. Deadline27 Mar 2025
  3. Published on judiciary.uk31 Jan 2025
  4. Today23 Oct 2026

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Sent toResponse
Northamptonshire Healthcare NHS Foundation TrustNamed in the report as “Northamptonshire Healthcare Foundation Trust”Response publishedPublished on judiciary.uk in January 2025.

The coroner’s concerns

The assessment from Talking Therapies on 20 November 2023 identified current escalating factors around not being allowed to see his children, and an upcoming court case in relation to this on 14 December 2023. Indeed he stated that if he was not allowed to see his children he would take his own life. Despite all this information being available the Urgent Care and Assessment Team did not accept the referral. Of grave concern is that the identity of the person at the Urgent Care and Assessment Team who declined the referral is not known and no notes were made of the referral. 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, 2025-0054
Added to Minute Book
8 Oct 2026
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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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