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recurance

Timothy Clayton

17 Apr 2024 · Coroner Caroline Topping · Surrey

The coroner's concerns

  1. 1. inadequate discharge planning

    “The policy in relation to discharge planning remains under review, including how families are to be involved, so it has not been possible to assess the adequacy of the new policy.”
  2. 2. unsafe discharge based on flawed capacity assessment

    “There was a misunderstanding by a clinician in relation to whether capacity to make a decision can be relied on to justify actions taken when the requisite information which needed to be considered by Mr [name redacted] in relation to that decision and its consequences had not been provided to him. Mr [name redacted] expressed wish to go home alone, without any care plan in place, was relied on, erroneously, to justify an unsafe discharge on the basis that he had capacity.”

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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