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Tessa Summers

22 Aug 2014 · Coroner David Horsley · Portsmouth & South East Hampshire
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The coroner's concerns

  1. 1. lack of documentation of rationale for risk assessment changes

    “I heard in evidence that the social workers who decided on amendments to [the deceased]'s risk assessment did not record in that document their rationale for downgrading her from high to low risk of self-harm and allowing her to have access to her medication which she could then take without supervision by her Shared Lives Carer”

Responses

2014-0383-Response-by-Hampshire-County-Council.pdf ↗· Hampshire County Council

Stated action · end of November 2014

“We will be undertaking a review of the training and support needs of the Shared Lives Carers when working alongside people with mental health and emotional problems. We will have reached conclusions on this by end of November 2014.”
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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