Luke Pearce
16 May 2024 · Coroner Kelly Dixon · Staffordshire and Stoke on Trent
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. delayed staff training on cell entry and emergency communications
“relevant training and guidance to equip staff to understand when and how to enter a cell in a medical emergency, and the appropriate use of Code Blue and Code Red communications in a medical emergency”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“The issue of the difference between a code blue and a code red is one about which | have written before.”
This report
“relevant training and guidance to equip staff to understand when and how to enter a cell in a medical emergency, and the appropriate use of Code Blue and Code Red communications in a medical emergency”
Identical hazardConfidence 0.90 · high
This report
“relevant training and guidance to equip staff to understand when and how to enter a cell in a medical emergency”
Later report
“The evidence of OSG [REDACTED] did not appear to demonstrate familiarity with the processes set out in this policy at the time of [the deceased]'s death”