David Douglas Hackman

here as regards how this specific incident and in particular its lessons are being disseminated to the wider health care community in England & Wales and in particular other Trusts: understand the general principle but would be grateful if you could please specifically explain relevant to this particular incident and the learning exercise that's been carried out as to how the lessons learned been communicated and if have not been communicated to review as to why no action is being taken in that respect with a view to the prevention of future deaths_ You are under duty to respond to this report within 56 days of the date of this report, namely by 5 November 2013, however, if you require an extension to that period then you will need to make timely request in writing to me_ Your response must contain details of the actions taken or proposed to be taken, setting out the timetable for action. If no action is to be taken then you must explain why no action is proposed. have sent copies of my report to the Chief Coroner and to the following interested persons - Executor Bevan Brittan, Solicitors representing The Great Western Hospital Avon & Wiltshire Mental Health Partnership (Caroline Saunders). have also copied this report to the The Rt_ Hon. Jeremy Hunt Secretary of State for Health and the Care Quality Commission: am also under a duty to send the Chief Coroner copy of your response_ The Chief Coroner 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 have have they may interest_ You may make representation to me, the Coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. Yours sincerely David Ridley Senior Coroner to: The Chief Coroner Executor Bevan Brittan Avon & Wiltshire Mental Health Partnership The Rt: Hon. Jeremy Hunt Secretary of State for Health Care Quality Commission Copy