Lesley Hanson
12 Oct 2017 · Coroner Philip Spinney · South Wales Central
The coroner's concerns
1. gate left open by other residents
“The evidence revealed that the care and risk assessments did not appear to consider the impact of the gate being left open by other residents, the type of stair-gate and the suitability of the locking mechanism.”
2. unclear responsibility for environment and control measures
“It was unclear from the evidence who had the responsibility for the environment and control measures to ensure residents safety at the property.”