UK Inquiry Tracker

Joan Prescott

PFD Report Historic (No Identified Response) Ref: 2021-0223

Date of Report 30 June 2021

Coroner Ian Arrow

Coroner Area Plymouth Torbay and South Devon

Response Deadline est. 25 August 2021

Community health care and emergency services related deaths Other related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

Safeguarding considerations, particularly regarding a known poor property condition, were not adequately recorded or prioritised during a welfare visit. This represented a missed opportunity to formally address broader safeguarding concerns.

View full coroner's concerns

_ [BRIEF SUMMARY OF MATTERS OF CONCERN] 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

Sent To

Devon County Council

Response Status

Linked responses 0 of 1

56-Day Deadline 25 Aug 2021

About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

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