Paul Kalnins

15 Jul 2015 · Coroner Nadia Persaud · London (East)

The coroner's concerns

1. lack of familiarity with Merlin database
“The communications officer confirmed that he had worked in his role for 15 years, but had had little need to obtain data from the Merlin database. Whilst he therefore had access to it, he was not familiar with it. He confirmed that he had last had training in 2011, in relation to the database.”
2. inability to locate required details
“The communications officer said that he did not know where to look for the required details. He explained that the database is complex to navigate. The front screen does not contain any key information relating to risk.”
3. absence of risk grade and explanation on front screen
“It was considered that the identification of the grade of risk (low, medium or high) on the front page, together with a brief explanation as to the type of risk posed, is likely to assist in prompting the communications officer to undertake a more detailed search of key parts of the database. [MMM suggested that the warning could be in red.”
4. lack of refresher training
“Mandatory refresher training for communications officers, may also reduce risk.”

Stated action · 31 March 2016

“the importance of this functionality will be part of the training that is set out below, with an intended completion date of 31 March 2016.”