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Rowan Thompson

2023-0365
Prevention of Future Deaths Report

Coroner

Coroner's area

Date of report

Read the PFD report for

Joanne Kearsley

Manchester North

1 November 2023

Report recipients

Hospitals and other NHS acute settings

MH unit (inc for people detained under MH Act)

Missed observations; falsified observation records; lack of supervision of newly qualified staff

Issues raised
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