Mark Vagnoni
11 Oct 2017 · Coroner Ian Pears · Bedfordshire & Luton
The coroner's concerns
1. lack of helpful NOMIS layout
“The jury expressed concerns that the NOMIS layout were not helpful to | Staff in that the staff needed to drill down beyond the initial screen to be alerted to past ACCTs”
2. absence of Wing Transfer documentation
“The jury were also concerned that there appears to be no Wing Transfer documentation, which could have included information about past ACCTs and indeed past risk factors”