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Tanya Page

2 Feb 2015 · Coroner ME Hassell · London Inner (North)
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The coroner's concerns

  1. 1. lack of communication of self-harm risk between wards

    “When Ms [name redacted] was transferred from Sapphire to Opal Ward, she disclosed that she had tried to hang herself whilst on Sapphire a few days before. Opal Ward staff members were shocked at this but, though they recorded the disclosure in the medical notes, they did not alert any staff member from Sapphire until after Ms [name redacted] death”

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.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error