Preventing Future Deaths 2023: Liam Bentley, Oleg Khala and Philip Malone

There were 16 PFDs following conclusions of inquests relating to autistic people in 2023, and I’ve reviewed some here and others here. This is the next three deaths, with one further post to follow. Liam Bentley was 25 when he died in June 2022. The Senior Coroner for Mid Kent and Medway, Patricia Harding, who […]

Preventing Future Deaths: Lucy Walles, Ryan Evans and Benn Curran-Nicholls

Previous posts as follows: Post 1: Lugh Baker and David Hemmings Post 2: Owen Garnett, Steven Duquemin and Matthew Dale Post 3: Claire Twinn, Mark McKessy and Shane West This is the final post reviewing 2023 Prevention of Future Death Reports into people with a learning disability (with/without autism). At some stage I will review […]

Preventing Future Deaths: Claire Twinn, Mark McKessy and Shane West

Continuing with the exploration of Prevention of Future Death reports issued in 2023 for learning disabled and/or autistic people, today I cover three more reports relating to learning disabled people. You can find the first post here and the second here. Claire Twinn Claire was 47 when she died in December 2022. She had Downs […]

Preventing Future Deaths: Lugh Baker and David Hemmings

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 […]

Peter Seaby’s 2nd inquest – record keeping and decision making

There were so many issues that emerged during the court of Peter’s second inquest. I can’t blog about all of them, but I wanted to just focus on record keeping and decision making at Oaks & Woodcroft, before the final post which will focus on the Prevention of Future Deaths evidence given by the Director […]

Peter Seaby’s 2nd inquest – May 2018

I’ve written a number of posts reporting Peter’s second inquest now, a quick recap incase this is the first one you’re coming to. There’s one about how he came to be in the care of the Priory Group here, one about support worker Siobhan Cator and her understanding of 1-1 supervision and refusal to have […]