Source · Prevention of Future Deaths
Joan Prescott
Ref: 2021-0223
Date: 30 Jun 2021
Coroner: Ian Arrow
Area: Plymouth Torbay and South Devon
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner noted a lack of recorded safeguarding discussions during a welfare visit and a missed opportunity to consider safeguarding at an earlier stage, as the initial focus was on immediate health needs.
Date
30 Jun 2021
56-day deadline
25 Aug 2021 est.
estimated from the report date
Responses identified
0 of 1
Coroner's concerns
The coroner noted a lack of recorded safeguarding discussions during a welfare visit and a missed opportunity to consider safeguarding at an earlier stage, as the initial focus was on immediate health needs.
View full coroner's concerns
_ Safeguarding Consideration at the time of the visit There was no reference in the recordings to a discussion on safeguarding being considered. Again, on interviewing the social workers they felt there was a need for GP involvement and for an admission, not safeguarding at that stage (missed opportunity). The social workers formed an opinion that the initial focus was not on the state of the property, which was a known situation, but on the immediate presenting potential physical and mental health needs, hence their plan to recommend to re-contact GP for involvement: There is a clear recording of this reflection and decision in notes following visit. Following_the welfare visit the GP was made aware (24/04/2020) of findings via the Duty Worker_ May
Report sections
Investigation and inquest
Joan Mary PRESCOTT Following an Inquest opened on the 22 2020 and an inquest hearing at HM Coroner's Court; Plymouth on the 25 June 2021 heard before lan Michael Arrow, in the coroner's area for Plymouth, Torbay and South Devon.
Circumstances of the death
The deceased lived alone. On the balance of probability, she was not compliant with her medication: On the balance of probability she neglected herself. She deteriorated. She was conveyed to hospital where she sadly died on 9th May 2020
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: Please review the action advised by
Similar PFD reports
Report details
- Reference
- 2021-0223
- Date of report
- 30 June 2021
- Coroner
- Ian Arrow
- Coroner area
- Plymouth Torbay and South Devon
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 25 Aug 2021 (estimated from the report date).
Sent to
- Devon County Council