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Georgia Scarff

4 Feb 2026 · Coroner Darren Stewart · Suffolk
Check this reportOriginal

The coroner's concerns

  1. 1. incomplete safeguarding record

    “not all staff were familiar with or proficient in the use of CPOMS which, although not causative of [the deceased]'s death, led to important information not being recorded in [the deceased]'s CPOMS record”

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