Skip to content
recurance

Guided path, Step 1 of 4

See a chainStart

Piotr Kucharz

24 Nov 2015 · Coroner Alan Wilson · Blackpool and Fylde
Check this reportOriginal

The coroner's concerns

  1. 1. inadequate patient observations

    “lack of consistency and clarity as regards what constitutes an effective observation”

Responses

2015-0465-Response.pdf ↗· Lancashire Care NHS Foundation Trust

Stated action · 31 March 2016

“The Trust is also in the process of reviewing the observation policy and procedure. We are taking into account the learning from previous serious incidents and national best practice.”
  • Built with
  • NVIDIA Nemotron Nano, Super and Ultra
  • Nebius Token Factory inference
  • Qwen3 Embedding 8B on Token Factory
  • Tavily follow-up web search
  • Postgres and pgvector search
  • Next.js site

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.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error