Thomas Loxton

“In the inquest, there was evidence that [the deceased]' family received letters from clinicians from Dudley Integrated Health and Care NHS Trust (DIH) requesting that [the deceased] made contact with them, which were sent after his death, causing obvious distress to his family. It is not difficult to see that this type of administrative error could lead to significant distress to families who are already vulnerable by virtue of their bereavement, and which could give rise to a risk of death. An RCA carried out”

“Upon conclusion of the inquest, I am Functus Officio, with no power to request updates from the Trust to check and ensure that the targets have been met and changes have been made. Whilst I am grateful for the efforts of reassurance provided by representatives of the Trust at the inquest, I am reluctant to dismiss my concerns, particularly where actions remain outstanding, and I have opportunity to take action now to ensure that the risk of future deaths is reduced.”