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recurance

Guildford and Waverley Clinical Commissioning Group

1
reports received
1
with a published response found
0
recurrence chains
0
reports in those chains
  • Sasha Forster23 May 2019

    Coroner David Reid · Hampshire (Central)

    Response
    Response · 1 stated action
    Sasha-Forster-2019-01693_Redacted.pdf ↗
    “I am also under a duty to send the Chief Coroner a copy of your response.”
    Response · 1 stated action
    Sasha-Forster-R2019-0169.pdf ↗
    “The Department therefore expects care providers to ensure that those members of staff involved in the return of a patient following revocation of section 17 leave are aware of their powers and responsibilities towards that patient and that these are applied in a consistent manner.”
    Response · 1 stated action
    Sasha-Forster-R2019-01692.pdf ↗
    “The PFD stated that clarification was required as to the actions that would be taken to achieve the goals set out in a letter dated 22 May 2019 from the Deputy Chief Executive of Surrey and Borders Partnership NHS Foundation Trust (SABP). This letter committed to the development of joint working protocols across the system for the management of complex absent without leave (AWOL) cases (cases where section 17 has been revoked and a person is AWOL).”
    Response · 1 stated action
    Sasha-Forster-R2019-01693.pdf ↗
    “[SABP] has a legal responsibility to arrange for the return to hospital of patients whose s.17 leave they have revoked. If resources are not provided to allow them to fulfil this legal responsibility, there is a risk that future patients, whose s.17 leave has been revoked and who remain at risk of self-harm or suicide whilst in the community, will find the opportunity to act in such a way as results in their death, whether intentionally or not.”
    Response · 1 stated action
    Sasha-Forster-R2019-01694.pdf ↗
    “we consider that this guidance, when followed, ensures safe prescribing and protects patient safety”
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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.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error