Henok Gebrsslasie
6 Mar 2025 · Coroner Delroy Henry · Coventry
The coroner's concerns
1. ligature anchor points
“The inquest explored issues such ligature anchor points”
2. lack of door top alarms
“door top alarms is "the way forward" as an environmental change that would mitigate such risk”
3. missing door top alarms
“no door top alarms on the patient bedroom doors at Sherbourne Ward, the Psychiatric Intensive Care Unit, at the Caludon Centre”