Henry Holcombe
15 Jul 2021 · Coroner Veronica Hamilton-Deeley · Brighton & Hove
The coroner's concerns
1. patients described as asleep but actually dead
“The ongoing failure of SPFT to require their staff to comply with the Trusts therapeutic engagement and observation policy. Especially those sections which relate to night times or when patients are believed to be sleeping (see para 4.5.5, 4.5.7 and table 1 -page 5). Since 27.12.2019 to 5.3.2021 there have 1 [name redacted], THE CORONER'S OFFICE LL.B.”