Mark Fernandez
4 Mar 2025 · Coroner Joanne Kearsley · Manchester North
The coroner's concerns
1. inadequate referral information
“The referral to the specialist service did not provide adequate information as to his level of care needs to help assist the service conduct an appropriate examination.”
2. failure to use hospital passport
“The hospital passport was not utilised.”
3. best interest decision without carer input
“A best interest decision was made without taking into account the views of the long-term carers and social services and their knowledge of him as an individual.”