Report dated 9 Jun 2023
Added from Judiciary.uk 13 Jun 2023
Reference 2023-0188
Coroner: Peter Nieto
East Midlands
Derby and Derbyshire
AI-generated concerns summaryThe coroner noted potential risks to patients from lengthy stays in discharge lounges and late-night transfers without full admission assessments, suggesting a need for robust discharge protocols. Concerns were also raised about delayed clinical review and confirmation of a surgical site infection, with missed opportunities to expedite blood results.
Addressed to: University Hospitals of Derby and Burton NHS Foundation Trust, Derbyshire Community Health Services NHS Foundation Trust and East Midlands Ambulance Service
0 responses identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 7 Jun 2023
Added from Judiciary.uk 13 Jun 2023
Reference 2023-0187
Coroner: Nicholas Rheinberg
North West
Lancashire and Blackburn with Darwen
AI-generated concerns summaryThe coroner raised concerns regarding the lack of readily available mouth protection for resuscitation in the prison, which posed a risk of blood-borne virus transmission to officers and could deter the provision of rescue breaths.
Addressed to: HM Prison and Probation Service
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 5 Jun 2023
Added from Judiciary.uk 12 Jun 2023
Reference 2023-0186
Coroner: Sophie Cartwright
East Midlands
Derby and Derbyshire
AI-generated concerns summaryThe coroner raised concerns regarding the insufficient number and availability of psychiatrists and psychologists within the Ministry of Defence, impacting serving personnel's access to appropriate treatment and diagnosis. This shortage was noted particularly in Northern Ireland and Scotland, affecting timely care.
Addressed to: Ministry of Defence; Nottinghamshire Healthcare NHS Foundation Trust
2 responses identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 8 Jun 2023
Added from Judiciary.uk 12 Jun 2023
Reference 2023-0185
Coroner: Kate Sutherland
Wales
North West Wales
AI-generated concerns summaryThe coroner noted that critical patient referral information, held in hard copy notes, was not accessible to staff using electronic systems in the Emergency Department. Concerns were also raised about the timeliness of the Health Board's investigation into the death, which took too long to finalise and share.
Addressed to: Betsi Cadwaladr University Health Board
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 8 Jun 2023
Added from Judiciary.uk 12 Jun 2023
Reference 2023-0184
Coroner: Kevin McLoughlin
Yorkshire and the Humber
West Yorkshire (Eastern)
AI-generated concerns summaryThe consent process did not provide sufficient information, including statistical risk ratings or personalised risks based on medical history, nor did it ensure the patient could make a truly informed decision while lucid.
Addressed to: Mid Yorkshire Hospitals NHS Trust
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 9 May 2023
Added from Judiciary.uk 12 Jun 2023
Reference 2023-0183
Coroner: Emma Serrano
West Midlands
Stoke on Trent and North Staffordshire
AI-generated concerns summaryThe coroner identified that rigid ambulance call categorisation pathways incorrectly classified a diabetic patient's serious condition. Concerns were also raised that the assessment team for category 3 calls lacks time limits and prioritisation, potentially causing delays and future deaths.
Addressed to: NHS England and West Midlands Ambulance Service
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 8 Jun 2023
Added from Judiciary.uk 12 Jun 2023
Reference 2023-0182
Coroner: Rachael Griffin
South West
Dorset
AI-generated concerns summaryThe required face-to-face mental health assessment for the detainee did not take place. The police custody system also lacked a structured way to record a detainee's first arrest and other key risk factors, hindering comprehensive risk assessment.
Addressed to: College of Policing, National Police Chiefs Council, Niche Technology, Maritime and Coastguard Agency, National Police Air Service, RNLI, Association of Ambulance, National Fire Chiefs Council, NHS England, Dorset Police, Dorset & Wiltshire & Rescue Service and South West Ambulance Service NHS Foundation Trust
11 responses identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 7 Jun 2023
Added from Judiciary.uk 12 Jun 2023
Reference 2023-0181
Coroner: Tom Osborne
South East
Milton Keynes
AI-generated concerns summarySymptoms of delirium were not highlighted to the GP, and there was no discussion with the patient's wife about delirium or discharge planning. The coroner noted that protocols for discharge following heart surgery should be reviewed.
Addressed to: John Radcliffe Hospital and MK together Partnership
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 7 Jun 2023
Added from Judiciary.uk 9 Jun 2023
Reference 2023-0180
Coroner: Martin Fleming
Yorkshire and the Humber
West Yorkshire (Western)
AI-generated concerns summaryThe coroner raises concerns that current guidelines for Ciprofloxacin and Quinolone antibiotics do not sufficiently emphasise a potential rare link to suicide behaviour, noting that prescribing doctors may lack full awareness of this side effect.
Addressed to: Medicines & Healthcare products Regulatory Agency
0 responses identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 2 Jun 2023
Added from Judiciary.uk 9 Jun 2023
Reference 2023-0179
Coroner: David Reid
West Midlands
Worcestershire
AI-generated concerns summaryThe coroner noted a lack of understanding between two NHS Trusts regarding processes for urgent mental health referrals and assessments, which meant an urgent assessment was not arranged as intended. This communication gap creates a risk of similar incidents if staff do not understand inter-trust referral procedures.
Addressed to: Herefordshire and Worcestershire Healthy and Care NHS Trust and Gloucestershire Health and Care NHS Foundation Trust
2 responses identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 2 Jun 2023
Added from Judiciary.uk 9 Jun 2023
Reference 2023-0178
Coroner: Michael Spencer
South East
East Sussex
AI-generated concerns summaryThe coroner noted a lack of clearly defined processes for new prisoners to make successful first contact with family members and for logging and handling incoming calls from family members with safety concerns or requesting welfare checks.
Addressed to: HM Prison and Probation Service
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 31 May 2023
Added from Judiciary.uk 2 Jun 2023
Reference 2023-0177
Coroner: John Gittins
Wales
North Wales East and Central
AI-generated concerns summaryThe health board lacks a documented and robust policy for decision-making, criteria, and future treatment pathways for patients referred to the Home Treatment Team.
Addressed to: Betsi Cadwaladr University Health Board
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 25 May 2023
Added from Judiciary.uk 2 Jun 2023
Reference 2023-0176
Coroner: Karen Dilks
North East
Newcastle upon Tyne and North Tyneside
AI-generated concerns summaryThe coroner noted common pedestrian crossing at non-designated points on B1286 Doxford Parkway, a lack of fencing to restrict access, and no signage warning of risks or prohibiting such crossings. A review of pedestrian crossing provision is recommended.
Addressed to: Sunderland City Council
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 30 May 2023
Added from Judiciary.uk 2 Jun 2023
Reference 2023-0175
Coroner: Rebecca Ollivere
West Midlands
Birmingham and Solihull
AI-generated concerns summaryThe coroner identified inadequate mandatory training for enhanced supervision and insufficient falls risk assessment training for new and agency staff. Concerns were also raised that falls risk assessment audits check compliance but not correctness, potentially overlooking errors and training needs.
Addressed to: Birmingham Community Healthcare NHS Foundation Trust
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 26 May 2023
Added from Judiciary.uk 2 Jun 2023
Reference 2023-0174
Coroner: Matthew Kewley
East Midlands
Derby and Derbyshire
AI-generated concerns summaryThe coroner identified gaps in communication and handover between hospitals regarding a patient's tinzaparin medication plan, and a lack of process for following up on care upon discharge. There were also concerns about insufficient documentation by consultants regarding the potential impact of KTS on the pregnancy.
Addressed to: Chesterfield Royal Hospital NHS Foundation Trust
0 responses identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 26 May 2023
Added from Judiciary.uk 2 Jun 2023
Reference 2023-0173
Coroner: Nadia Persaud
London
East London
AI-generated concerns summaryThe coroner identified insufficient liaison and information sharing between specialist and step-down mental health services for a BDD patient on discharge. Concerns included a lack of risk communication regarding aesthetic treatments for BDD, and limited national resources and training.
Addressed to: Department of Health and Social Care; NHS England and Tatiana Aesthetic Dermatology Clinic; North East London Foundation Trust; Royal College of Psychiatrists; South London & Maudsley NHS Foundation Trust
4 responses identified · 5 indexed addressees. Read concerns and response evidence →
Report dated 12 May 2023
Added from Judiciary.uk 1 Jun 2023
Reference 2023-0172
Coroner: Jacqueline Devonish
North West
Cheshire
AI-generated concerns summaryThe coroner noted a lack of pre-sentence or post-sentence review for the offender, and that details of a restraining order were not effectively communicated within the prison or to community rehabilitation services. This meant staff were unaware of the order and its breaches, impacting risk assessment and recall procedures.
Addressed to: HMP Altcourse, Ministry of Justice and HM Prison and Probation Service
2 responses identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 24 May 2023
Added from Judiciary.uk 1 Jun 2023
Reference 2023-0171
Coroner: Jason Pegg
South East
Hampshire, Portsmouth and Southampton
AI-generated concerns summaryA continuing risk to life exists at 2, The Haven, Gosport, Hampshire, due to carbon monoxide exposure. The source, likely faulty heating/cooking apparatus or ventilation, has not yet been identified.
Addressed to: Churchers Solicitors
0 responses identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 23 May 2023
Added from Judiciary.uk 1 Jun 2023
Reference 2023-0170
Coroner: Paul Rogers
London
Inner West London
AI-generated concerns summaryPolice officer training does not sufficiently focus on understanding mental health conditions' symptoms and presentation, nor on practical strategies to optimise decision-making in situations involving mental ill-health.
Addressed to: College of Policing; Metropolitan Police Service
0 responses identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 22 May 2023
Added from Judiciary.uk 1 Jun 2023
Reference 2023-0169
Coroner: Guy Davies
South West
Cornwall and the Isles of Scilly
AI-generated concerns summaryThe coroner noted faded deflection arrows and visibility issues near a roundabout, alongside a marginal overtaking opportunity at the collision site. A recommendation to remove the downhill overtaking section lacks funding for implementation.
Addressed to: Connectivity and Environment
1 response identified · 1 indexed addressee. Read concerns and response evidence →