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recurance

Benjamin Brown

5 Sept 2016 · Coroner Andrew Walker · London (North)

The coroner's concerns

  1. 1. inadequate auditing of staff conducting 15 minute observations

    “The auditing of those persons carrying out 15 minute observations”
  2. 2. insufficient resuscitation training for staff

    “Training of staff for resuscitation in the event that a patient collapses”
  3. 3. inadequate auditing of clozapine prescription and management

    “The auditing for the prescription and management of clozapine”

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