Gordon Penistan

31 Oct 2017 · Coroner Grahame Short · Hampshire (Central)

The coroner's concerns

1. lack of adequate communication and coordination in care placement
“Adults' services in other local authority areas are likely to experience similar cases and could | benefit from the lessons learnt from the review in this case and the actions taken by Hampshire Coroner's Office, Castle Hill, The Castle, Winchester, SO23 8UL Tel 01962-667884 | Fax 01962-667893 County Council to address the shortcomings highlighted by the death.”
2. lack of information sharing across local authorities
“The Association would be in a position to share this information with other Adult Services”
3. absence of best interests meeting
“no "best interests" meeting and a lack of adequate communication with the case worker and with the family”

Responses

2017-0313-Response-by-ADASS.pdf ↗· Adult Social Services

Stated action · Tuesday 31 October

“We would like to draw your attention to a situation where a Coroner has issued a Regulation 28 Report (Prevention of Future Deaths). The circumstances and learning have been shared by the DASS concerned. Please see this confidential briefing for further information.”