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Ben Harrison

22 Mar 2023 · Coroner Kate Sutherland · North Wales East and Central
Check this reportOriginal

The coroner's concerns

  1. 1. delayed implementation of learning and actions

    “learning and actions arising therefrom are not more quickly addressed”

  2. 2. lack of strategic direction

    “evident lack of overall strategic direction to investigations and learning”

Responses

No published response was found on judiciary.uk.

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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.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error