Mark Groombridge
17 Apr 2015 · Coroner Andrew Haigh · Staffordshire (South)
The coroner's concerns
1. lack of direct conversation between local offender manager and clinician before recall
“Before the recall paperwork was issued there was no direct conversation between the local offender manager and the clinician responsible for Mr [name redacted] care in hospital”
2. confusion about recall process
“There was confusion about the recall process. The local offender manager believed that recall papers could be sent to the central NOMS unit in London and that they could be held there pending further direction”