John Robinson

In the circumstances it is my statutory duty to report to _ The evidence at inquest suggested Mr Robinson required a psychiatric bed on Dovedale but no such bed was available_ His condition deteriorated and he ultimately died_ The concern is whether sufficient resources are available in this area_ ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action: YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Wednesday, 18lh November 2015. may extend the period_ Your response must contain details of action taken or proposed to be taken, setting out the timetable for action: Otherwise you must explain why no action is proposed COPIES and PUBLICATION have sent a copy of my report to the Chief Coroner and to the following Interested Persons (who are not under a duty to respond): (family) {family) {Clinical Commissioning Group) am also under a duty to send the Chief Coroner a copy of your response_ The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me; the coroner, at the time Of your response, about the release or the publication of your response by the Chief Coroner . 75 September 2015 David Urpeth May you.