Paula Speirs
4 Mar 2021 · Coroner Mary Hassell · Inner North London
The coroner's concerns
1. intoxication without monitoring
“staff formed the view that she was intoxicated”
2. absence of observation protocol
“no formal observations were ordered or undertaken”
3. lack of positional asphyxia guidance
“Speirs were not given any instructions on how to avoid positional asphyxia.”