What is a Prevention of Future Deaths report? Coroners have a duty to take action, when they become aware of circumstances during the course of their investigation that they consider creates a risk of deaths occurring. The duty is quite broad and is not restricted to matters revealed in evidence at the inquest. Paragraph 7 […]
You can read the coroner’s summing up in three posts: Conclusion 1, Conclusion 2 and Conclusion 3. In this post I report on the coroner’s conclusion. This is what he said. I’ve considered Professor Gilmore’s evidence carefully, I now incorporate into these findings the evidence of Professor Gilmore which I accepted. I make these findings […]
Conclusion 1 reported the coroner’s summing up of events up until the day before Sally died. Conclusion 2 reported the coroner’s summing up of the events surrounding Sally’s death, post mortem evidence and cause of death. This post will discuss the coroner’s summing up in relation to what happened after Sally’s death including an internal […]
I’m reporting the coroner’s summing up and conclusion in stages. The first post is here. This post will cover what the coroner concluded about the events of Sally’s death, the post mortem findings and the cause of death. The coroner said that on Thursday 26 October 2017 Sally had enjoyed what appeared to be a […]
Sally Lewis’s inquest concluded this afternoon with the coroner finding that her death was contributed to by neglect. David Reid, Senior Coroner for Worcestershire said that no short form conclusion could properly describe or summarise the events in this case, so he’d give a short narrative conclusion. I’m going to report this in stages, this […]
Today, the final day of Sally’s inquest, her sister Julie Bennett addressed the court, reading a pen portrait of her sister Sally. The coroner invited her to take her time, to pause, or they could break if necessary. This is what she said: Even though Sally was at Sunfield when Terry and I came along, […]
The final witness that we heard from on Day 3 was Julie Harris from Worcestershire County Council. She is an Advanced Social Work Professional in the Safeguarding Adults Team at Worcestershire CC and she managed to speak loudly, clearly and into the microphone and it was an auditory relief. We heard she was the author […]
The first witness on Day 3 of Sally’s inquest was the court appointed expert, Professor Sir Ian Gilmore. He gave an affirmation and started by explaining that more evidence had come to light since he’d submitted his report and that’s why he’d shared two medical journal articles. Professor Gilmore gave his name, affiliation and an […]
The final two Dimensions UK witnesses were Deborah Hubbocks, a Health and Safety Advisor for Dimensions who conducted their internal investigation after Sally died, and Lorna Owen who was a Support Worker who left Dimensions before Sally died, and her statement was read onto the record by the coroner. Deborah Hubbocks Deborah Hubbocks spoke very […]
I’m reporting these witnesses slightly out of order because we heard from the court appointed expert first thing on Day 3, but I’ll finish the Dimensions witnesses first. Ms Campbell was taken through her evidence and questioned by the coroner for about 45 minutes before lunch, and by other counsel for half an hour after […]