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Karen Thomason

2 May 2024 · Coroner Robert Cohen · Cumbria
Check this reportOriginal

The coroner's concerns

  1. 1. safeguarding question errors

    “There were errors in the completion of the hospital's safeguarding questions. The clinician answered 'no' to the question 'Is there a safeguarding concern?'”

  2. 2. lack of discharge notification to housing staff

    “Cumbria Housing staff had asked to be notified of the discharge of a vulnerable patient so that they could provide support to her but that they received no communications on several occasions”

  3. 3. capacity and vulnerability conflation

    “the concepts of 'having capacity' and 'not being vulnerable' are being elided”

Responses

2024-0244-Response-from-North-Cumbria-Integrated-Care.pdf ↗

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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