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recurance

Hazel Lewis

6 Nov 2019 · Coroner Catherine McKenna · Manchester (North)

The coroner's concerns

  1. 1. inadequate MCA training for life-sustaining treatment decisions

    “evidence was given that all witnesses had undergone mandatory Mental Capacity Act 2005 (MCA) training, the Court was left with some concerns about the adequacy of that training as it relates to decisions concerning life-sustaining treatment”
  2. 2. premature best interest decision without prior consultation

    “best interest decision not to proceed with investigations in this case was taken prior to consultation with those involved in the Deceased's care”
  3. 3. lack of awareness of consultation status

    “Neither the social worker or community learning disability nurse appreciated that they were being consulted when spoken to by the GP.”
  4. 4. exclusion of primary carers from decision making

    “carers who provided daily care to the Deceased and who had been able to foster her engagement with social care were not consulted”
  5. 5. absence of independent mental capacity advocate involvement

    “An IMCA was not formally instructed.”
  6. 6. lack of alternative support strategies exploration

    “no exploration of or advice given in relation to the options available to support the Deceased in engaging with medical investigations or medica! care such as desensitisation or 1:1 care”

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.

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Hazel Lewis · Recurance