Geoffrey Banks
27 Nov 2020 · Coroner Margaret Jones · Stoke-on-Trent & North Staffordshire
The coroner's concerns
1. unsecured medication storage leading to overdose
“The tenant was easily able to pull open the cupboard door and the barrel of the lock fell out. He overdosed on medication. There appears to be no system of safe storage in place where a resident has been identified as being in need of supervision with medication.”
2. inadequate incident investigation
“The apparent investigation into the incident was perfunctory and carried out by an untrained member of staff.”