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recurance

Jessica Birkhead

2 Jun 2016 · Coroner John Tomalin · Exeter and Greater Devon

The coroner's concerns

  1. 1. inadequate support services for individuals with learning disabilities

    “Although [the deceased] had been referred to a Consultant [name redacted] in learning disability, the other support services offered to [the deceased] were main stream adult services, [the deceased]'s mother, a GP, is of the view that they were not equipped to deal with someone of [the deceased]'s intellectual disabilities.”
  2. 2. inappropriate pathways for future cases with learning disabilities

    “Perhaps [the deceased]'s case could be looked at to consider the appropriate pathway for others in the future in a similar situation to [the deceased] to give appropriate support and care at a level appropriate taking into account any learning difficulties and associated medical problems.”

Responses

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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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