John Tompkins
11 Feb 2025 · Coroner R Brittain · Inner London North
The coroner's concerns
1. limited internal review of death circumstances
“limited internal review of the circumstances of Mr [name redacted]' death, following identification that the procedures were undertaken at the same time”
2. non consideration of NatSSIPS2 standards
“Trust seemingly did not consider the NatSSIPS2 standards either when undertaking the procedures, nor in detail as part of its review following the inquest”