Recurance · prevention of future deaths reports
Pre-inquest brief
Recurring hazard (see the quoted concerns)
The earlier warning
Sally Poynton · 14 May 2024 · Andrew Cox, Cornwall and the Isles of Scilly
“A failure to advise [the deceased], as Nearest Relative, of her statutory right to request [REDACTED] assessment under the MHA.”
judiciary.uk/…/sally-poynton-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Sally Poynton (14 May 2024) · stated timescale: 8 July 2024
“The ICB has taken this matter seriously and the executive leadership of the ICB were presented with a paper in a formal executive group meeting. The paper provided an analysis of this issue and a proposal for how it should be addressed. The meeting took place on the 8 July 2024 and supported the proposal; which is described in this letter.”
judiciary.uk/…/2024-0267-Response-Integrated-Care-Board-Office-…
Stated action 2 · response to Sally Poynton (14 May 2024) · stated timescale: next 6 months
“We are continuing to work with colleagues through the Domestic Homicide Review process to identify actions stemming from the Senior Coroner's proposed recommendations.”
What recurred
- 29 May 2025 · Callum Hargreaves (5) · Andrew Cox · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · Sally Poynton · 14 May 2024
“A failure to advise [the deceased], as Nearest Relative, of her statutory right to request [REDACTED] assessment under the MHA.”
Later · Callum Hargreaves (5) · 29 May 2025
“The Nearest Relative details on the MH 1 form were not completed.”
What happened next
No web check of the stated actions has been published for this chain.