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recurance

Darren Williams

6 Nov 2019 · Coroner Tom Osborne · Milton Keynes

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

The coroner's concerns

  1. 1. lack of healthcare presence during ACCT reviews

    “ACCT reviews were being conducted on many occasions without someone from Healthcare being in attendance”

Linked reports

Repeats an earlier warningIan Brown26 May 2016 · 3 years 5 months earlier
Closely relatedConfidence 0.90 · high

Earlier report

“(1)During the course of the evidence | was referred to the most recent report from the HM Inspector of Prisons that highlighted”
Original on judiciary.uk ↗

This report

“it became apparent during the course of the evidence that ACCT reviews were being conducted on many occasions without someone from Healthcare being in attendance.”
Full chain: Inadequate ACCT documentation and healthcare absence during reviews

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