Jonathan Lander
PFD Report
All Responded
Ref: 2016-0114
All 1 response received
· Deadline: 13 May 2016
Response Status
Responses
1 of 1
56-Day Deadline
13 May 2016
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns
During (he coursa Df the Inquest the ew dence revealed matters giving risa t0 concern In my opirion there is a risk that future Ceaths will occur unless action is taken; In the circumstarzes it i5 MY statutary duty t reportto You Tha MATTERS QF CONCERN are 38 follows {1} That there Is not In Flace any polcy Or procedure tor [ha tolawing up Qf Individuals wha are #2en Dy One GETYice and [herealler d %charged to anather service In the coursa of Ine inguest was Frovided wth a Root Cause Analysis which identifed the merticned above and which containad an actipn plan indicating that such & policy proredure was to bP implemented by September 2015 was told in the coumse of the inquest thatthat policy procedure has not baen implemented, was laf with tne serse thatthis ia still io ba czns Jered but there Appears to be no wense of urgerty was furtner tcld tnat tha Tnusi has a governance prccedure t0 ersure thai acticn plans are "fcllowed through" put it weems tc pe clearly the case that this nas not worked either tne the being falling respectfully sugge8t that you consider Urgenlly Ihe necessity for a such J procedure / policy and t0 Implemgnt Il 2p {31 ACTION shouLD BE TAKEN In my opiion aclion shoud ne taken t2 prevant future deaths ad believe You have Ihe powe: lo lake such action;
Responses
Response received
View full response
Dear Mr Wlliam; Johnathan James Lander (Doceased) Thank you (or your letter dated 22 March 2016 issued pursuant to Regulatian 28 cf the Coroner: Regulations Fallowing the inquest the Trust now has in place an agreed Substance Misuse Inforratrion Sharing Protocol between itself and Swanswell Worcestershire Recovery Partnership encloze & copy for your Ba8e Df reterence The puipose of ihe protocol is Io erisure relevant clinical and otrer material information Is shared where there are concerns regarding patieni $ menlal health ad subatance misuse Ip ensure that services have UP Io date informaticn and Ihal patierts will receive the appropriate treatmert bath agencies_ can advise In relaticn [o & govemance procedure to implement the Action Plans set out in individual Root Cause Analyses thaf the Trust ncw' has an Emherded Lessons Database AIl the Action Plans sot out in Individual Root Cause Analyses aTa now uploaded t0 that database together wilh evidence of completed actions, This database is mcnitored by Ine Coverance Team based in the Ajult Mental Health and Leamning Disability Service Delivery Unit note that the issues ralsed In thiz cage may be l relevance to thcse Froviding healncare services in alher Trusts nationally an can see that tnere may b2 merit in the Chief Coroner publishing either 3 :ummary ar redacted form of cur correspondence shall be graleful If you cculd kindly sond a copy of my letter tol hope the above addresses Your concerns however_ if You have any quenes do not hesitale to ccntact me.
Report Sections
Circumstances of the Death
On 28" Aprl 2015 Mr Lander %as killed when he was struck by a brain on Ihe bracks near to Black Bndge, Woicester Rcad Hartlebury.
Similar PFD Reports
Reports sharing organisations, categories, or themes with this PFD
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
London Fire Brigade to establish lessons learned process
Grenfell Tower Inquiry
No open learning culture
Ensure Home Office staff presence and visibility in IRCs
Brook House Inquiry
No open learning culture
Review international practice on medics with firearms officers
Manchester Arena Inquiry
No open learning culture
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.