We always strive to do everything we can to ensure we provide the highest possible standards of care at Oxford Health, but there were actions that could have been better performed in this case, and for those we are sorry.

Following Mr Skrebowski’s tragic death, the trust has undertaken a review of our services and implemented a number of changes based on our own review.

We are also awaiting the findings of an independently commissioned report by NHS England, which we hope will provide further assurances to both Mr Skrebowski’s family and the wider community we serve.

The Trust will now carefully consider all of the evidence heard at the inquest, along with the findings of NHS England review, to ensure any necessary changes which have not already been made are fully addressed.