Katharine Corrigan
1 Jun 2026 · Coroner Sonia Hayes · Essex
This report repeats 4 earlier warnings. See the linked reports.
The coroner's concerns
1. prevented therapy for hormonal imbalance
“Ms [name redacted] was undergoing recognised therapy consistent with the national guidelines for a pre-existing hormonal imbalance prior to her detention under the Mental Health Act and was prevented from continuing with it”
2. inadequate section 17 leave risk assessments
“Policies and protocols on section 17 Leave granted under the Mental Health Act (Section 17 Leave) were not properly understood by all staff and the required risk assessments were not conducted by appropriately qualified and trained staff”
3. electronic system omitted detailed leave information
“Section 17 Leave forms and the process of recording of the required components for timings and conditions of such leave had been changed by the Trust in May 2023 from a paper system to electronic recording”
4. missing Datix reports for unauthorised leave
“There was a lack of Datix reports for Ms [name redacted] accessing Section 17 leave when the leave had been rescinded by the Responsible Clinician”
5. unauthorised leave facilitated by staff
“Ms [name redacted] was absent without leave on multiple occasions and this had been facilitated by staff”
6. inadequate risk assessments and care plans
“Corrigan's risk assessment and care plans had not been appropriately updated in her medical records such that: a. They had not been developed in collaboration with her and did not contain: i. Early waring signs and triggers”
7. inadequate supervision of preceptorship nurses
“Preceptorship nurses were left in charge on the mental health ward on the morning of 22 July 2023 and a qualified nurse attended several hours after the commencement of the shift”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“There was no evidence of any adequate formulation of risk prior to [the deceased]'s discharge from hospital on the 14 December 2022 and no evidence of any adequate risk formulation prior to [the deceased]'s discharge from the community mental health team in January 2023.”
This report
“Ms [name redacted] risk assessment and care plans had not been appropriately updated in her medical records such that: a. They had not been developed in collaboration with her and did not contain: i. Early waring signs and triggers”
Closely relatedConfidence 0.92 · high
Earlier report
“Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to [the deceased]'s risk assessment consistent with Trust policy.”
This report
“Ms [name redacted] risk assessment and care plans had not been appropriately updated in her medical records such that:”
Closely relatedConfidence 0.80 · moderate
Earlier report
“Multiple experienced members of the mental health teams had contact with Mrs [name redacted] between January and March and did not make detailed entries into the medical”
This report
“Ms [name redacted] risk assessment and care plans had not been appropriately updated in her medical records such that:”
Closely relatedConfidence 0.80 · moderate
Earlier report
“(c) Failures in Risk Assessments: specifically, failures to appropriately up- date and document matters relating to Mr [name redacted] risk assessment consistent with Trust policy.”
This report
“6. Ms [name redacted] risk assessment and care plans had not been appropriately updated in her medical records such that:”