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recurance

Geoffrey Whatling

27 Oct 2023 · Coroner Jacqueline Lake · Norfolk

The coroner's concerns

  1. 1. insufficient nutrition and hydration

    “Mr [name redacted] was not eating and drinking very much. A food and fluid chart was not fully completed.”
  2. 2. delayed emergency response

    “Emergency services were not called on 8 April 2023 when Mr [name redacted] scored NEWS2 7 as required.”
  3. 3. communication breakdown in escalation

    “The evidence so far revealed is that 111 call taker was not made aware Mr [name redacted] had scored NEWS2 7.”
  4. 4. inadequate vital sign monitoring

    “Mr [name redacted] observations were not taken hourly as required.”
  5. 5. incomplete record keeping

    “Some of Mr [name redacted] observations were recorded on a piece of paper and were not logged in his Care Records”
  6. 6. delayed managerial oversight

    “The Manager only became aware of gaps in the records following concerns raised by the family.”

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