Richard was 33 when he died from unmanaged constipation <<< again not sure whether to include that on front page, especially given in his case he was failed by so many people, United Response, his GP, his psychiatrist and Ipswich Hospital

Richard’s family compiled this video to introduce him to the coroner and interested persons at his inquest:

<<< I have a copy of this video and am sure that Emily (Richard’s sister who put it together) would let us embed if we wanted. It’s hosted on Rightful Lives at the mo but they’ve restricted embedding it from vimeo.

Quote 1 about the person

Lorem ipsum scelerisque malesuada nisi, et rhoncus diam semper vitae. Phasellus eget massa nisl.  [best friend]

Quote 2 about the person

Lorem ipsum scelerisque malesuada nisi, et rhoncus diam semper vitae. Phasellus eget massa nisl.  [support worker]

— REFERENCED REPORTS —

Report from independent researcher
etc.
etc.

— PROFILE DETAILS —

These are taken from the Bristol research form – they don’t work (copied and pasted in) but we can decide what is required to build the template for individual records. https://www.bris.ac.uk/sps/leder/notification-system/
Notification of death
1. Your name:

2. Your job and employing organisation (if relevant):

3. How did you know the person who died?
Please provide your contact details (if you are happy to be contacted):

4. Telephone number:
Please enter a valid phone number.
5. Email address:
Please enter a valid email address.

6. Postal address and postcode:

7. How would you prefer us to contact you?

8. Who else has been notified about the death? (Please tick all that apply)
To my knowledge, no one else has been notified
Coroner
Safeguarding Team
Child Death Review
Police
Care Quality Commission
Someone else
I don’t know
a. If someone else has been notified about the death, please provide their contact details if you have them:
About the person who died

9. What was the FIRST (GIVEN) NAME of the person who died?

10. What was the LAST NAME (i.e. family name or surname) of the person who died?

11. Was the person known by any other name? If so please write this here:

12. Can you give us their date of BIRTH please? (If not known, leave blank)

Dates need to be in the format ‘DD/MM/YYYY’, for example 27/03/1980.
Open date-picker

(dd/mm/yyyy)
13. Can you give us their date of DEATH please? (If not known, leave blank)

Dates need to be in the format ‘DD/MM/YYYY’, for example 27/03/1980.
Open date-picker

(dd/mm/yyyy)
14. How old were they when they died?

15. Gender of the person who died:
Male
Female
Other
a. If ‘Other’, please describe:

16. How did the deceased person identify their ethnic group?
a. Details of person’s ethnic group:

17. Can you tell us the marital status of the person who died?
Single (never married)
Married / civil partnership
Separated (but still legally married / in a civil partnership)
Divorced
Widowed
I don’t know

18. In which area of England was the person registered with a GP?
North: Yorkshire and the Humber
North: Lancashire
North: Greater Manchester
North: Cumbria & the North East
North: Cheshire & Merseyside
Midlands & East: North Midlands
Midlands & East: Central Midlands
Midlands & East: West Midlands
Midlands & East: East of England
South West: South West South
South West: South West North
South East: Hampshire, IOW and Thames Valley
South East: Kent, Surrey and Sussex
London Region
I don’t know
Not registered with a GP

19. If you know their NHS number, please provide it here. (This should be in the following standard format 000 000 0000):

20. Did the person who died have any known medical conditions or health problems?

21. What level of learning disability did the person who died have?
Mild
Moderate
Severe
Profound / multiple
I don’t know

22. What was the usual address of the person who died?
a. What was the post code? (It is very helpful if you can provide this.)

Please enter a valid UK postcode.

23. Did the person who died usually live alone?
Yes
No
I don’t know

24. Was the person who died placed out-of-area, either in a residential / nursing placement or in a supported living tenancy?
Yes
No
I don’t know
a. If yes, please state which area was their original ‘home’:

25. Was the person who died subject to any restrictive legislation?
None
Deprivation of Liberty Safeguards (DOLS) – approved
Deprivation of Liberty Safeguards (DOLS) – applied for
Section of the Mental Health Act
Detention in police custody / imprisonment
Other
I don’t know
a. If you selected Other, please specify:
b. If the person was subject to any restrictive legislation, please describe more fully (e.g. dates, reason for restriction):
Someone who knew the person who died
26. Name of someone who knew the person well:
a. Their telephone number:
b. Their email address:

Please enter a valid email address.
c. Their address and postcode:

27. How did they know the person who died?

Please can you provide the name and contact details of the person’s GP.

28. GP Name:
a. Surgery contact details: (It is extremely helpful if you can provide the surgery postcode.)
About the death

29. Where did the person die?
Hospital
Usual place of residence
Hospice / palliative care unit
Home of relative or friend
Residential / nursing home that was not usual address
I don’t know
Other
a. If you selected Other, please specify:
b. If the person died in hospital, please state the name of the hospital, NHS Trust or Foundation Trust (if known):

30. What was the cause of death as described on the Cause of Death Certificate? (If you do not know, please leave blank.)
I (a) Disease or condition leading directly to death
I (b) Other disease or condition, if any, leading to I(a)
I (c) Other disease or condition, if any, leading to I(b)
II Other significant conditions contributing to death but not related to the disease or condition causing it

31. What do you think the cause of death was?

32. Will there be a post mortem?
Yes
No
I don’t know

33. Will there be a Coroner’s inquest?
Yes
No
I don’t know

34. Will there be any other investigation or review of the death?
Yes
No
I don’t know
a. If yes, please describe:

35. Do you have any comments about this person’s death?

36. Please confirm that you have included all the information that you wish to provide, and you are ready to submit it. Required
I am ready to submit my information