John McKinlay

I am Emma Brown HM Area Coroner for the coroner area of Birmingham and Solihull

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. I have a duty to send a copy of your response to the Chief Coroner. In accordance with the Chief Coroner’s Publication Policy, you should send me any representations regarding the publication of your response. These representations should be  made at the same time as the response is provided. I will pass any representations received to the Chief Coroner for a decision. Please note any links to webpages included in the response will not be checked for sensitive  information prior to publication, as the information is already online. The names of those who do not respond to PFD reports are regularly published on the Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports – Courts and Tribunals Judiciary .

SUMMARY OF THE CORONER’S CONCERN 1) The number of falls occurring when the Deceased did not have supervision in accordance with his falls risk assessment. 2) The absence of evidence of a thorough investigation into all the falls with learning points and  an action plan.