2025-0045
20 Jan 2025 · Coroner Ian Potter · Inner North London
The coroner's concerns
1. delay in welfare check
“it nevertheless took hours for the request for a welfare check to be actioned in any way”
2. lack of immediate assistance
“no positive or definitive action was taken to assist for over an hour”
3. failure to provide first aid
“did not attempt to render basic assistance or first aid to Student A”
4. inadequate staff training
“lack of appropriate training in place for staff or, if there is such training in place, that it may not be effective”
5. unaddressed future risks
“future risks posed by my concerns have been addressed.”