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Samuel Jones

2023-0499

Prevention of Future Deaths Report

Coroner

Rachael Griffin

Coroner's area

Dorset

Date of report

5 December 2023

Read the PFD report for

Report recipients

Healthcare staff in prison setting (inc MH)

Issues raised

System configuration and functionality

Information absent/incomplete

Not listening to the person or their family/carer

Information not sought; lack of professional curiosity; capacity not considered

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