Daniel Ludlam
7 Jun 2022 · Coroner Katrina Hepburn · Central & South East Kent
The coroner's concerns
1. miscommunication due to learning disability
“The NHS Pathways triage system for the calls that were made did not appear to take specific account of the patient who had a learning disability”
2. lack of protocol for learning disability callers
“There appears to be no procedure or specific protocol in place to deal with a caller with learning disabilities”
3. absence of carer advocacy for learning disabled callers
“The carer assisting [the deceased] had to interpret the questions from the call handler in a way that [the deceased] could easily understand and then relay the responses back”