Lugh Baker
13 Mar 2023 · Coroner Andrew Cox · Cornwall and the Isles of Scilly
The coroner's concerns
1. inadequate resident monitoring
“all residents were constantly monitored yet I found as fact that there were times when this did not happen for [the deceased]”
2. delayed care plan review
“Care Plans for new residents were not reviewed sufficiently promptly”
3. lack of training for unusual conditions
“what steps will be taken, and when, where a new resident with an unusual presentation is admitted”