Dorothy Breislin
4 Dec 2017 · Coroner Paul Cooper · Lincolnshire
The coroner's concerns
1. delay in receiving Incident Review Report
“The incident date was 27" January 2015. The Incident Review Report was not received in this office until 10" August 2017. Why the delay”
2. lack of documented apology
“$.13 recites an apology has been provided verbally and in writing. The families ask who made the apology. Also, when and where as they are adamant they have never received one.”
3. non-implementation of Action Plan
“P| confirmed on oath that none of the Action Plan referred to in the Appendices at 3 have been implemented. If not, in view of the Incident Date why not?”