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Serena Nicolle

22 Jun 2021 · Coroner Anna Crawford · Surrey
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The coroner's concerns

  1. 1. unreliable chest/abdomen observation through cell hatch

    “The observation of an individual's chest/abdomen through a cell door hatch may be an unreliable method of checking whether they are breathing, in circumstances in which they are not otherwise moving or responding to prison staff, and therefore gives rise to the risk of future deaths”

Responses

No published response was found on judiciary.uk.

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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.

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

Serena Nicolle · Recurance