Samantha Boazman
31 Jan 2023 · Coroner Fiona Butler · Leicester City and South Leicestershire
The coroner's concerns
1. delayed provision of emergency equipment
“when an alarm sounded staff would attend the location of the alarm, assess the situation and then go and collect what equipment may be necessary to deal with the emergency”
2. inconsistent observation recording
“Observations are a therapeutic intervention aimed at reducing factors which contribute to increased risk and promoting recovery”