Skip to content
recurance

David Clark

6 Feb 2020 · Coroner Neil Cronin · Lancashire & Blackburn with Darwen

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

The coroner's concerns

  1. 1. incomplete leave documentation

    “documentation in relation to leave was not completed fully and incorrect forms used”
  2. 2. AWOL procedure not followed

    “AWOL procedure was not followed”
  3. 3. lack of handover between Safety and Security workers

    “a handover was not undertaken between Safety and Security workers”
  4. 4. lack of training on policy and procedure

    “lack of training on policy and procedure”
  5. 5. outstanding insufficient action plan

    “there remains outstanding an appropriately sufficient action plan”

Linked reports

Repeats an earlier warningAdam Carter12 Jul 2018 · 1 year 7 months earlier
Closely relatedConfidence 0.90 · high

Earlier report

“e Hecould not find a copy of the Leave Authorisation that granted [the deceased] leave and felt that documentation of leave fell short of the guidance laid out in the Trust policy for the authorisation of section 17 leave of absence.”
Original on judiciary.uk ↗

This report

“(1) That documentation in relation to leave was not completed fully and incorrect forms used”
Full chain: Incomplete patient leave documentation

Responses

  • Built with
  • NVIDIA Nemotron Nano, Super and Ultra
  • Nebius Token Factory inference
  • Qwen3 Embedding 8B on Token Factory
  • Tavily follow-up web search
  • Postgres and pgvector search
  • Next.js site

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