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recurance

Ryan Merna

5 Apr 2022 · Coroner Richard Middleton · Dorset

The coroner's concerns

  1. 1. lack of accommodation inquiry

    “The members of the Dorset Forensic Team did not probe as to where the perpetrator was sleeping”
  2. 2. knife possession not investigated

    “The disclosure made by the perpetrator that he was in possession of a knife was not probed further by the Social Worker”
  3. 3. knife possession not documented

    “The disclosure made by the perpetrator that he was in possession of a knife was not recorded contemporaneously in the perpetrator's records”
  4. 4. knife possession not escalated

    “The disclosure made by the perpetrator that he was in possession of a knife was not raised during a Care Programme Meeting held the day following the disclosure”
  5. 5. inadequate accommodation identification

    “The Trust Clinical Risk Policy should make reference to the fact that i. The Trust should use its best endeavours to identify where a service user is living by reference to information to be sourced from the individual and from that which may be in the public domain”
  6. 6. documentation and escalation of weapon possession lacking

    “Where there is disclosure that a service user is in possession of an offensive weapon this must be documented; there must be a documented discussion as to the response; the information must be passed to the police; any action taken by the Trust and/or the police to be documented”

Responses

No published response was found on judiciary.uk.

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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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