“Mr Siirak was discovered in his room, having been assaulted, at 1647 hours on 1 March 2020”

The coroner’s concerns

Mr Siirak was discovered in his room, having been assaulted, at 1647 hours on 1 March 2020. The crash team, led by , arrived at 1703 hours. The evidence was that between those times (until took charge at 1703) the response of ward staff to the incident was "chaotic" and "panicking" (as was acknowledged by the staff). The evidence was that various members of your staff had never previously been involved in a real or simulated emergency. By "simulated emergency", I mean an unexpected dummy run on the ward, as opposed to training in the calm confines of a planned day. One member of staff told the court that she had never been involved in an unexpected simulated emergency in the 14 years of working on the ward prior to 1 March 2020, nor in the 4 years since. The jury found that "there was a clear failure to provide the adequate training in simulation exercises to effectively manage situations like the one that occurred on 1st March 2020." It was equally clear on the evidence that members of staff have still not undergone unexpected simulation training.

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, 2024-0174

Added to Minute Book

8 Oct 2026

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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