Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of national guidance on family engagement in care plans
The earlier warning
Steven Cooke · 30 Dec 2020 · Emma Serrano, Stoke-on-Trent and North Staffordshire Coroner's Court
“That there is no national guidance regarding engagement with the family of a Mental Health patient”
judiciary.uk/prevention-of-future-death-reports/steven-cooke
What was promised
No published response from NHS England was found for the earlier reports.
What recurred
- 11 Oct 2025 · Joanna Chamberlain · Joseph Turner · Identical hazard · confidence 0.92 (high)
The clearest link, quoted from both reports:
Earlier · Steven Cooke · 30 Dec 2020
“That there is no national guidance regarding engagement with the family of a Mental Health patient”
Later · Joanna Chamberlain · 11 Oct 2025
“there is a potential need for clearer national guidance on, direction to and protocols for clinicians to proactively seek and include the views and input of family members”
What happened next
No web check of the stated actions has been published for this chain.