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Charlie Millers

2024-0225
Prevention of Future Deaths Report

Coroner

Coroner's area

Date of report

Read the PFD report for

Joanne Kearsley

Manchester North

26 April 2024

Report recipients

MH unit (inc for people detained under MH Act)

Information about the frequency of Charlie's observations was not completed until after his death. The Coroner noted two earlier PFD reports about the same MHU which raised the same concern.

Issues raised
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