Asher Sinclair
4 Sept 2022 · Coroner Lydia Brown · West London
The coroner's concerns
1. inadequate ventilator dependent child care
“[the deceased] was entirely dependent upon a complex package of care as a highly vulnerable ventilator dependent child”
2. lack of review of care package
“most expensive was not appropriately reviewed and there was no mandatory system of quality checks or formal review when there was a significant change in family circumstances. Quarterly”
3. absence of quarterly reviews
“Quarterly reviews were not carried out without explanation”
4. inadequate staff training
“Training for the staff involved was unclear to the court and seemingly not in place or inadequate”
5. delayed implementation of new structures
“new structures would be in place by July 2022”