Notification of death whilst deprived of liberty



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Case ID Number

DEPRIVATION OF LIBERTY SAFEGUARDS FORM 12

NOTIFICATION OF DEATH WHILST DEPRIVED OF LIBERTY

Full name of person who was deprived of their liberty




Date of Birth (or estimated age if unknown)




Est. Age




Date of Death




Location of person at time of death




Name and address of the care home or hospital where the person was being deprived of their liberty


Name and contact details of family member / RPR



Name of the Supervisory Body



Person to contact at Supervisory Body

Name

DoLS Team


Telephone

01785 895665


Email

deprivationofliberty@staffordshire.gov.uk


Contact details of the GP

Name



Address



Telephone



As soon as practicable the Managing Authority must also give a copy of this notice to the

Supervisory Body for the hospital or care home




Signed

(on behalf of the Managing Authority)

Name




Print Name




Position




Date






January 2015 – V3 Deprivation of Liberty Safeguards Form 12 Page of

Notification to Coroner





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