Mark Bartholomew
21 May 2014 · Coroner Simon Nelson · Manchester (North)
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. inadequate emergency service response
“the response to external emergency services was inadequate”
2. delay in ligature release
“time was very much of the essence”
3. inadequate equipment checks
“the practice of daily checks for equipment has now been superseded by a check at the commencement of each shift”
4. inadequate observation documentation
“actual observation sheet apparently in use at present indicates a poor level of detail as to who and when it is completed”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“actual observation sheet apparently in use at present indicates a poor level of detail as to who and when it is completed”
Later report
“there should be a clear written policy or protocol setting out what those observations actually involve (e.g. what 1 in every 15 minutes means and precisely what should be recorded)”
Responses
No published response was found on judiciary.uk.