Christopher James Morgan
PFD Report
Historic (No Identified Response)
Ref: 2013-0272
Coroner's Concerns (AI summary)
The Trust lacks clear policies for communicating risk level changes and leave access with family, and has no defined staff-to-patient ratio for escorted leave from psychiatric wards.
View full coroner's concerns
That before any change in identified level of risk is decided upon, particularly in relation to access to leave, there is communication with all relevant parties concerned including family and carers to elicit their views The Trust should ensure that a clear practice and policy is adopted in relation to the ratio of staff to patient as to staff that should accompany patients on escorted leave from psychiatric wards
Sent To
- Cambridgeshire and Peterborough NHS Foundation Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
12 Feb 2014
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 29th November 2012 | commenced an investigation into the death of Christopher James MORGAN aged 39 years_ The investigation concluded at the end of the inquest on Friday 27ih September 2013. The conclusion of the inquest was that Christopher James Morgan died on November 2013 at Ely Railway Station; the cause of his death was multiple injuries recorded a narrative verdict (see below)
Circumstances of the Death
Narrative Verdict Christopher Morgan, voluntary patient at Friends Ward, Fulbourn Hospital, Cambridgeshire, took his own life, dying from multiple injuries when he dived in front of a train at or near Ely Railway Station, on 27th November 2012, in circumstances where he had run away from Fulbourn Hospital earlier in the and in circumstances where there was not in place in the hospital a formal risk assessment covering his supervision at the material time_
Action Should Be Taken
27/h day
In my opinion action should be taken to prevent future deaths and believe that your organisation have the power to take such action.
In my opinion action should be taken to prevent future deaths and believe that your organisation have the power to take such action.
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Computerise system for managing missing persons and casualty information
Ladbroke Grove Inquiry
Emergency family notification
Increase driver briefing frequency with safety as primary agenda item
Ladbroke Grove Inquiry
Staff rota communication
Extend computerisation to all police forces for shared information access
Ladbroke Grove Inquiry
Emergency family notification
Establish common telephone numbers for public major incident information
Ladbroke Grove Inquiry
Emergency family notification
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.