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You are in the PFD Zone

Sobhia Khan

2024-0088

Prevention of Future Deaths Report

Coroner

Coroner's area

Date of report

Read the PFD report for

Clement Goldstone

Derby and Derbyshire

16 February 2024

Report recipients

Private sector healthcare provider commissioned by NHS

Ministry of Justice (acting under Part III MHA 1983)

Multi-Agency Public Protection Arrangements (Police, Probation, Prison Service)

Issues raised

1.3.1 Information absent/incomplete

2.1.3. Failure to communicate - external (other teams, services, professions, organisations)

2.1.4. Failure to communicate - discharge information

2.2.4. Lack of cultural awareness

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

2.3.4. Other failure of policy, process, practice or professionalism

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