Charlie Todd
21 Sept 2021 · Coroner James Thompson · County Durham and Darlington
The coroner's concerns
1. lack of supervising officer
“no supervising officer present on a day to day basis to ensure key tasks were always allocated or completed”
2. incomplete hourly checks
“document setting out which hourly checks had been undertaken in the SACU was incomplete”
3. absence of real time monitoring
“no 'real time' system which would alert officers and their supervisors to checks being incomplete”