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recurance

Lisa Thompson

10 Feb 2021 · Coroner Sonia Hayes · Oxfordshire

The coroner's concerns

  1. 1. lack of clear care plan

    “There was no clear care plan in place following an emergency review of Mrs [name redacted] on 13th March 2020”
  2. 2. incomplete risk assessment

    “2) The care plans and risk assessments at the mental health Trust were not updated: (a) with material information on the facts and circumstances of Mrs [name redacted] overdoses of her medication. (b) the two most recent overdoses were not recorded (c) with further information disclosed by the doctor who treated her most recent overdose that Mrs [name redacted] had lied about the severity of her overdose that it was probably double that which she initially disclosed also that this was her 4th overdose and another”
  3. 3. lack of follow-up after review

    “on 13th March 2020 following a review with the Trust Consultant [name redacted] (e) on 13th March 2020 when there was a telephone conversation between Mrs [name redacted] and her care co-ordinator”

Responses

2021-0171-Response-from-Littlemore-Mental-Health-Centre-Redacted.pdf ↗· Oxford Health NHS Foundation Trust

Stated action

“the Trust has been on notice of your concerns and had the opportunity to include your concerns as part of the investigation into Mr [name redacted] complaint.”
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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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Lisa Thompson · Recurance