Melissa Mathieson
21 Jul 2025 · Coroner M. E. Voisin · Avon
The coroner's concerns
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”