PM explains why new system is better Coroner: So what you’re saying to me is at the time her referrals were made, over time they should have been actioned in the way now they would be, in Colette’s case there were failures in making the MHA assessment? PM: Yes I believe so

PM explains why new system is better Coroner: So what you’re saying to me is at the time her referrals were made, over time they should have been actioned in the way now they would be, in Colette’s case there were failures in making the MHA assessment? PM: Yes I believe so