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recurance

Christopher Roberts

5 Oct 2017 · Coroner Aled Gruffydd · Swansea, Neath and Port Talbot

The coroner's concerns

  1. 1. lack of documented care plan review

    “The care plan review was not recorded which would not allow another person reviewing the file to ascertain that a care plan review had taken place and what the outcome of that review was. It was also the case that a lack of documentation would not demonstrate whether CMHT had considered the matter of the attempt on his own life by the deceased in the weeks leading up to that review, when considering whether to amend or retain the care plan in place at the time.”
  2. 2. inappropriate medication dispensing

    “Nomad trays may be unsuitable in dispensing medication to some patients, which may deprive them of the benefits in taking that medication.”

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.

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