In the circumstances it is my statutory to report to you_ _ Doctors must ensure that all relevant information is accessed and read even if this is in the Nursing notes as opposed to the Clinical records_ It is clear that the information which prompted an urgent CT scan on the 11th January had been available in Mr Felstead's medical records since the 7th January and his helmet had in fact been at the hospital. ACTION SHOULD BE TAKEN believe that this level of information should be mandatory in all Care establishments and in my opinion action should be taken to prevent future deaths and believe your organisation, has the power to take such action: YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report; namely by 11th March 2014. !, the coroner; may extend the period: 7th duty

Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION have sent a copy of my report to the Chief Coroner and to the following Interested Persons, namely the family of the deceased_ Choice Support, the Care Quality Commission and the Coroners' Society Website. am also under a duty to send the Chief Coroner a of your response The Chief Coroner may publish either or both in a complete or redacted or summary form_ He may send a copy of this report to any person who he believes may find it useful or of interest You may make representations to me; the coroner; at the time of your response, about the release or the publication of your response by the Chief Coroner: 14 January 2014 Joanne Kearsley HM Area Coroner copy