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recurance

Melissa Mathieson

21 Jul 2025 · Coroner M. E. Voisin · Avon

The coroner's concerns

  1. 1. misleading placement and supervision

    “the offer of placement and the level of supervision i.e. 1:1 was misleading, there was no clarification for example, 24hrs cover, 8hrs cover during the day only, or when carrying out activities or when outside the home only”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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