Kiefer Fraser-Phillips
14 Apr 2026 · Coroner Louise Hunt · Birmingham and Solihull
The coroner's concerns
1. observations not recorded accurately and effectively
“Staff had not been completing the comments section during therapeutic observations as the electronic device they used would drop Wi-Fi signal making it impossible to record the observations until they were back in the ward office”
2. lack of care plan for physical health risks
“There was no care plan in place to address these risks”