Alexander Lyalushko
25 Mar 2024 · Coroner Amanda Bewley · Nottingham and Nottinghamshire
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. inadequate review and incident investigation following a death
“Inadequate review and incident investigation following a death”
Linked reports
Closely relatedConfidence 0.78 · moderate
Earlier report
“The quality of the Trust's own investigation into the circumstances of Mr [name redacted] death. It failed to identify themes of concern.”
This report
“it did not identify that a request from Mr [name redacted] GP in November 2022 for involvement of its service with Mr [name redacted] had not been actioned;”