Matthew Gale
13 Aug 2024 · Coroner Simon Connolly · County Durham and Darlington
The coroner's concerns
1. lack of communication of section 17 leave conditions to family
“no evidence in any records available to it that such discussions had been had with [the deceased]'s mother or that a copy of the section 17 leave form had been provided to her”
2. inconsistent compliance with section 17 leave form provision
“risk that future deaths could occur consequent to this change unless action is taken”