Michelle Dawes

I am Isobel Thistlethwaite, Assistant Coroner for The Black Country Jurisdiction.

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations)  Regulations 2013.

Walsall Healthcare NHS Trust You are under a duty to respond to this report within 56 days of the date of this report, namely by 19 th June 2026. I, the coroner, may extend the period if an  appropriate application is made.

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. I have a duty to send a copy of your response to the Chief Coroner. In accordance with the Chief Coroner’s Publication Policy, you should send me any representations regarding publication of your response. These  representations should be made at the same time as the response is provided. I will pass any representations received to the Chief Coroner for a decision. Please note any links to webpages included in the response will not be  checked for sensitive information prior to publication, as the information is already online . The names of those who do not respond to PFD reports are regularly  published on the Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports – Courts and Tribunals Judiciary.

SUMMARY OF CORONER’S CONCERN I am concerned that despite the Trust acknowledging missed opportunities and delays and identifying required improvements, it will take up to twelve months  after Mrs Dawes’ death to fully implement those changes, with no interim  measures in place, thereby undermining learning from deaths and leaving an  ongoing risk to patient safety.