“That documentation in relation to leave was not completed fully and incorrect forms used…”
Dated 6 Feb 2020, from the coroner for Lancashire and Blackburn with Darwen. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 2 Apr 2020.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated6 Feb 2020
- Deadline2 Apr 2020
- Published on judiciary.uk8 Feb 2020
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Lancashire & South Cumbria NHS Foundation TrustNamed in the report as “Lancashire Care NHS Trust” | Response publishedPublished on judiciary.uk in February 2020. |
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— (1) That documentation in relation to leave was not completed fully and incorrect forms used (2) That the AWOL procedure was not followed. (3) That a handover was not undertaken between Safety and Security workers. (4) That there was a lack of training on policy and procedure. (4) That there remains outstanding an appropriately sufficient action plan. Coroner's Court, 2 Faraday Court, Faraday Drive, Fulwood, Preston, Lancashire, PR2 9NB ‘Tel 0172 536536 | Fux 01772 530752 ‘ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2020-0023
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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