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Karen Thomason

2024-0244

Prevention of Future Deaths Report

Coroner

Coroner's area

Date of report

Read the PFD report for

Robert Cohen

Cumbria

2 May 2024

Report recipients

Hospitals and other NHS acute settings

Issues raised

1.1.2 System configuration and functionality

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

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