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recurance

Warren Green

1 Dec 2025 · Coroner Jeane Mellani · Essex

The coroner's concerns

  1. 1. high risk of self-harm patients leaving acute ward

    “The evidence identified a risk of patients at high risk of self-harm being able to leave the acute ward without appropriate risk assessment”
  2. 2. high risk of self-harm patients leaving acute ward

    “The evidence identified a risk of patients at high risk of self-harm being able to leave the acute ward without the knowledge of the hospital staff”
  3. 3. lack of Consultant's oversight for vulnerable patients

    “The evidence showed that the Mental Health Liaison Service relies on nurses to conduct initial assessments and follow up reviews of patients suffering with mental health issues and the mechanism by which escalation to a Consultants Psychiatric is decided and the factors to be taken into account for escalation are not at all clear. This leads to lack of Consultant's oversight for these vulnerable patients.”

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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