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"this should not have happened and should never be allowed to happen again to another vulnerable person or their family.
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mr mcgurgan found that one nurse had added to her original account of what had happened on the ward on the morning of july 16, 2016 to state that "the cot sides were up". .
"we have to thank the coroner and his office for the work they have done. they have clearly listened to all of the evidence and came to the conclusion the family had all along. .
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