Alex Blake

1. 1. unreliable witness testimony

   “During the course of the inquest, the evidence revealed concerns with the implications of the evidence of three witnesses employed by NHS Professionals at times when the deceased was already dead. This leads me to have an opinion that there is still a risk that future deaths will occur unless action is taken with respect to these individuals.”

2. 2. failure to use lighting equipment

   “The first was RMN T, who gave evidence that the deceased was half out of bed, wearing pyjamas and she assumed to be asleep at 05.00. When asked whether he could have been dead, the nurse said she did not know, but it was too dark to see and no torch was used. She chose to wait until 06.00 to conduct a proper observation. She could not answer the question why she had not gone to get a torch or returned before 06.00. When found in the same position an hour later, she says she was concerned and ask”

3. 3. inaccurate electronic documentation

   “The second was RMN E, whose evidence was read due to his unavailability. He made an entry in the electronic journal at 05.59, which is about the time which he was found dead, that”

4. 4. misinterpretation of visual cues

   “The third was health care assistant K, whose evidence in court was that the deceased was observed at 03.00 and he held his phone in his hand which was lit up, and so assumed to be watching a film. The witness was unable to answer why he had then recorded the deceased as being asleep, as it would be likely then that the light of the phone would not be visible.”

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