Skip to content
recurance

Elsie Tindle

8 Mar 2016 · Coroner Derek Winter · Sunderland

The coroner's concerns

  1. 1. inadequate SOAD provision

    “I heard evidence that the present compliment of SOADs is approximately 105 and that in 2014/15 they carried out 14,373 visits. 25% of cases with a SOAD led to changes in a treatment plan and in 3% of cases the SOAD did not approve the plan. The SOAD safeguard in theory can prevent the inappropriate use of ECT.”
  2. 2. delayed SOAD attendance

    “For ECT, SOADs attend within 5 days in 82% of cases but I am concerned that in 1:5 cases this does not happen.”
  3. 3. default use of s62 MHA

    “Lam concerned that there is a danger of the use of s62 MHA becoming a default position and that the numbers of SOADs may be insufficient to deal with matters in a more timely way.”
  4. 4. lack of proactive follow-up

    “each of the agencies had reviewed practices and procedures, particularly Northumberland Tyne and Wear NHS Foundation Trust, who were to set up a system for the treating Psychiatrist to chase the CQC in the absence of a timely appointment of a SOAD.”

Responses

  • Built with
  • NVIDIA Nemotron Nano, Super and Ultra
  • Nebius Token Factory inference
  • Qwen3 Embedding 8B on Token Factory
  • Tavily follow-up web search
  • Postgres and pgvector search
  • Next.js site

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.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error

Elsie Tindle · Recurance