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recurance

Kimberley Parsons

4 Mar 2015 · Coroner P Harrowing · Avon

The coroner's concerns

  1. 1. assisted self-harm in high-risk patient

    “The suggestion made to Ms. [name redacted], a person with a history of self harming and who remained at high risk of self-harming, that she could be assisted with self- harming was not an approach to patient care and treatment which was supported by any reference to the results of any research published in a peer-reviewed professional journal. Therefore if this is a bona fide approach to treatment in a high risk patient then the Trust should be able to justify that this is a recognised and generally”
  2. 2. unrecorded discussion about assisted self-harm

    “This discussion with regard to 'assisted self-harming' was not discussed by the nurse with the consultant psychiatrist nor was any record made of the discussion.”

Responses

2015-0077-Response-by-Avon-Wiltshire-NHS-Trust.pdf ↗· Avon and Wiltshire Mental Health Partnership NHS Trust

2015-0077-Response-by-Care-Quality-Commission.pdf ↗· Care Quality Commission

Stated action

“we did not provide a rating (we now rate organisations on a four point scale - outstanding, good, requires improvement and inadequate against these key areas)”

Parsons-2015-0077a.pdf ↗· Avon and Wiltshire Mental Health Partnership NHS Trust

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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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