Rachael Walker
16 Mar 2023 · Coroner Peter Nieto · Derby and Derbyshire
The coroner's concerns
1. lack of robust processes to prevent avoidable deaths
“having heard evidence from the Trust as to 'lessons learnt' and its current processes for identifying when Trust clinical policies and guidance needs updating, and where essential equipment needs to be obtained and located, I remain unclear that the Trust now has sufficiently robust processes in place to prevent similarly avoidable deaths to that of [name redacted]”