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Naomi Sourbut

19 Dec 2017 · Coroner John Tomalin · Exeter and Greater Devon
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The coroner's concerns

  1. 1. lack of implementation of recommendations

    “1) A root cause analysis investigation was undertaken by the Devon Partnership Trust and that report was finalised on the 8 September 2017. The report contained a number of identified lessons learned and recommendations, ten in total (see attached annexe), applicable to different teams within Devon Partnership Trust. It was unclear at the Inquest as to whether or not these recommendations have been considered and acted upon by the teams to which they were directed particularly where clients have”

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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