Skip to content
recurance

Irene Fitches

18 Feb 2022 · Coroner Jacqueline Lake · Norfolk

The coroner's concerns

  1. 1. non-compliant falls policy

    “The present Falls Policy does not comply with NICE Guidelines”
  2. 2. incomplete falls policy development

    “Evidence was heard that a Falls Policy was drafted, and a Risk Assessment trialled at the beginning of 2020, the Covid-19 pandemic intervened and delayed its completion”
  3. 3. no falls lead appointed

    “There is no person appointed as Falls Lead. The job application has not yet been advertised, although it is recognised that someone is required to lead the Falls process”
  4. 4. lack of staff training

    “Staff will need training and the training package has not yet been developed”
  5. 5. delayed assisted technology implementation

    “Assisted Technology is being considered to alert staff to movements and the needs of patients. This has not been progressed since October 2021 and is still at an early stage”

Responses

No published response was found on judiciary.uk.

  • Built with
  • NVIDIA Nemotron Nano, Super and Ultra
  • Nebius Token Factory inference
  • Qwen3 Embedding 8B on Token Factory
  • Tavily follow-up web search
  • Postgres and pgvector search
  • Next.js site

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