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Bathsheba Shepherd

28 Mar 2021 · Coroner Dr Sean Cummings · London (West)

The coroner's concerns

  1. 1. lack of resolution of Care Programme Approach between local authority and NHS Trust

    “I was concerned to find that even though 5 years had elapsed between [name redacted]'s death and the hearing of the Inquest the issue of the way in which the Care Programme Approach was being conducted between the local authority and the NHS Trust was still the subject of discussion and had not been resolved to the satisfaction of the manager responsible for the process. The delay in my view represents a threat to the lives of others in similar situations.”
  2. 2. failure to register with a GP

    “I was concerned by evidence in the course of the Inquest that the disengagement of a person with known psychological illness from the process of registration with a GP by her failure to obtain relevant documentary proof to enable registration meant that she could not be registered. Registration with a regular GP would in my mind have provided additional support to her. This may have enabled her to raise concerns or fears relating to her accommodation and housemate.”

Responses

No published response was found on judiciary.uk.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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Bathsheba Shepherd · Recurance