Rebecca Gilbank
26 Jul 2016 · Coroner Anna Crawford · Surrey
The coroner's concerns
1. lack of check at 1.30am on 12 May 2015
“Lack of check at 1.30am on 12 May 2015”
2. lack of knowledge about how to obtain an outside line
“Evidence at the inquest revealed that the staff on duty did not know how to obtain an outside line to call emergency services and, after trying, had to rely on a personal mobile phone. This resulted in a delay of unknown duration”