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recurance

Kenneth King

27 Nov 2024 · Coroner Jacqueline Lake · Norfolk

The coroner's concerns

  1. 1. lack of formal structure for physiological observations

    “Evidence was heard that there is no formal structure in place as to when or with regard to the frequency of carrying out physiological observations on patients in the community. Observations are required to be taken if the attending clinician has any concerns about the patient's wellbeing or a deterioration in their condition, or at the request of a senior clinician or GP. No specific questions are asked of the patient, such as if they are feeling unwell, have pain or localised heat, the att”
  2. 2. delayed implementation of training and policy

    “Mr [name redacted] died a year ago and although there is a training programme which is being devised and rolled out it is not expected to be in place for a further eighteen months. The policy to prevent bank staff applying for roles when they have not undergone the required training is not yet in place.”

Responses

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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.

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