Investigation and inquest
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Circumstances of the death
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Coroner’s concerns
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Issued 12 Aug 2015•Hertfordshire
This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.
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Described in responses
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This section does not appear in the published report.
This section does not appear in the published report.
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Provide links to patient-safety and learning-disability hospital-care guidance and good-practice resources.
Introducing a purple-folder or similar system in England is an operational matter for NHS England and individual NHS trusts.
Deployment of a similar purple-folder system in Wales is the responsibility of the Welsh Assembly.
Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations
Data last updated 7 September 2026