Nyall Brown
15 Apr 2019 · Coroner Jacqueline Lake · Norfolk
The coroner's concerns
1. lack of review of care records
“Evidence was heard that Mr [name redacted] care records were not reviewed prior to his being seen, which would enable Mr [name redacted] full history and risks to be taken into account when assessing him”
2. failure to read previous records
“Staff are expected to read previous records relating to a service user, but this is not always happening”
3. matter not considered in investigation
“This matter was not considered in the otherwise thorough investigation conducted by the Trust”