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recurance

Daniel Futers

2 Feb 2023 · Coroner Derek Winter · Sunderland

This report repeats 1 earlier warning. See the linked reports.

The coroner's concerns

  1. 1. incomplete telephone information recording

    “The recording of information, particularly that conveyed by telephone, was not as comprehensive as it ought to have been. For example, a record of an altercation had not been made.”
  2. 2. inadequate discharge planning

    “Comprehensive planning for home leave and discharge from hospital was not evident, including contingency planning and the involvement of the family.”
  3. 3. lack of situational awareness

    “Overall situational awareness about [the deceased] was not evident, including the reconciliation of conflicting accounts about him.”

Linked reports

Repeats an earlier warningCharlotte Grace29 Oct 2019 · 3 years 3 months earlier
Closely relatedConfidence 0.80 · moderate

Earlier report

“(1) [the deceased] was discharged despite there being no input from those to whose care she was being entrusted.”
Original on judiciary.uk ↗

This report

“Comprehensive planning for home leave and discharge from hospital was not evident, including contingency planning and the involvement of the family.”
Full chain: Discharge without family involvement in planning

Responses

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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