Investigation and inquest
On 3.12.15, I commenced an investigation into the death of Abigail Hall. The investigation concluded at the end of the inquest on 12.9.18. The conclusion of the inquest was Accidental Death.
Circumstances of the death
Miss Hall died at home on 23.9.15. She died of 1 (a) Aspiration Pneumonitis 1(b) Viral Gastro-enteritis
Coroner’s concerns
During the inquest, evidence showed:-
There was no defibrillator at the premises nor were Derwent staff first aid trained. This position apparently still persists.