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recurance

Neil Black

21 Jan 2019 · Coroner Louise Hunt · Birmingham and Solihull

The coroner's concerns

  1. 1. lack of joint handovers between IDTS and primary care nurses

    “Consideration needs to be given to joint handovers to ensure those prisoners with joint needs have a coordinated approach”
  2. 2. animosity and unclear responsibilities between IDTS and primary care nurses

    “Consideration needs to be given to improving the relationship and making it clearer who is responsible for what observations”
  3. 3. absence of protocol for examining injection sites and DVT sites

    “Consideration needs to be given to ensure there is a clear protocol for the examination of injection sites and DVT sites”

Responses

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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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