“In the course of the inquest, I heard evidence that: 1) Bluebird Care provided care at…”
Dated 18 Sep 2023, from the coroner for Worcestershire. Sent to 3 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 13 Nov 2023. A reply may have been sent and not yet published.
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.
- Report dated18 Sep 2023
- Deadline13 Nov 2023
- Published on judiciary.uk18 Sep 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Bluebird Care | Response publishedPublished on judiciary.uk in September 2023. |
| Herefordshire and Worcestershire Health and Care NHS Trust | Response publishedPublished on judiciary.uk in September 2023. |
| Divine Health Services | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 13 Nov 2023. A reply may have been sent and not yet published. |
The coroner’s concerns
– In the course of the inquest, I heard evidence that: 1) Bluebird Care provided care at home for Mr. Friend up to 16.4.23 ( two days before the accident which led to Mr. Friend’s death ); 2) the reason Bluebird Care stopped providing care for Mr. Friend was that they had concerns about the sling which was still being used with his hoist; 3) Bluebird Care knew by 12.4.23 that Mr. Friend’s care at home after 16.4.23 would be provided by Divine Health Services Ltd.; 4) At no time did Bluebird Care try to make contact with, or provide any sort of handover to Divine Health Services Ltd. about Mr. Friend’s needs, or about any concerns they had concerning the sling. In her evidence to the inquest, 1 , Bluebird Care’s registered care manager, agreed that it was “common sense…for there to be a good handover between care agencies”, but that it “was not something which we had ever done”.
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, 2023-0336
- Added to Minute Book
- 8 Oct 2026
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- 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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