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Alfie Mains-Forster

9 Nov 2023 · Coroner Crispin Oliver · County Durham and Darlington
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The coroner's concerns

  1. 1. risk assessment not mapping national guidance

    “the current risk assessment (NEWS) does not map the national guidance fully and if would be more user- friendly, and thereby assist towards more effective, and therefore safer, risk assessment for it to map the national guidance completely”

  2. 2. NEWTT2 chart not available

    “The current NEWTT2 chart is not yet available and it would assist in the more effective management of risk for it to be on BadgerNet.”

Responses

2023-0459-Response-from-System-Connecting-Care.pdf ↗

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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Alfie Mains-Forster · Recurance