Sasha Mishabi
1 Nov 2023 · Coroner Emma Brown · Birmingham and Solihull
The coroner's concerns
1. pressure ulcer development
“Awareness of and compliance with St. Andrew's Healthcare 'Pressure Ulcer Prevention and Management' Policy”
2. lack of serious incident investigation
“SAH Governance, Quality Assurance and Serious Incident processors”
3. failure to identify compliance failures
“SAH Deputy Medical Director”