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recurance

Timothy Cowen

7 Oct 2014 · Coroner John Gittins · North Wales (East & Central)

The coroner's concerns

  1. 1. lack of mandatory training for staff on new procedures and protocols

    “That although a Root Cause Analysis undertaken by the health board has resulted in new training bundles being produced, training is not mandatory for all staff who would require to be made aware of the new procedures and protocols.”
  2. 2. lack of cover for Acute Liaison Nurse when absent

    “there are only three such ALNs and there is no cover in place when they are absent through illness or holidays”

Responses

No published response was found on judiciary.uk.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error