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recurance

Michael Harman

25 Nov 2014 · Coroner Jacqueline Lake · Norfolk

The coroner's concerns

  1. 1. lack of verification of self-cleaning

    “After being found in a soiled condition, no check was made on Mr [name redacted] to ensure he had cleaned himself as he said he would do.”
  2. 2. unsuitable independent living

    “There were several indicators that Mr [name redacted] condition had possibly deteriorated to a point where he was no longer suitable for independent living, such as his flat being unusually untidy, his relapse in respect of drinking alcohol, his having soiled himself, his physical problems (he had recently been diagnosed with cellulitis). He was also receiving the maximum amount of support which could be offered.”
  3. 3. inadequate review frequency

    “Reviews of a tenant such as Mr [name redacted] are annual, unless the tenant requests a review. No thought had been given to anyone else carrying out a review of Mr [name redacted] condition particularly in the light of the above factors”
  4. 4. missing cleaning verification in handover

    “Handover notes between Co-Ordinator and Cover Co-Ordinator deal with whether a tenant is likely to be at home when the intercom call is made. No note was made requesting a check to be made to ensure Mr [name redacted] had cleaned himself up.”

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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Michael Harman · Recurance