Report dated 15 Sep 2022
Added from Judiciary.uk 6 Oct 2022
Reference 2022-0288
Coroner: Emma Whitting
East of England
Bedfordshire and Luton
AI-generated concerns summaryPolice had not adopted specific guidance for managing sexual and violent offenders, and proactive information sharing to protect children was lacking. Concerns also related to the absence of an offender register for those with child cruelty convictions and non-mandatory health visitor safeguarding assessments for co-parent risks.
Addressed to: Metropolitan Police, College of Policing, Police Chief’s Council, Department of Health of Social Care and Home Office
4 responses identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 21 Nov 2022
Added from Judiciary.uk 6 Oct 2022
Reference 2022-0287
Coroner: Elizabeth Didcock
East Midlands
Nottinghamshire and Nottingham
AI-generated concerns summaryThe coroner raised concerns regarding repeated interference with or disposal of placentas prior to reporting early neonatal deaths, which limits pathologists' ability to determine the cause of death. This practice undermines coronial investigations, hinders learning, and deprives parents of crucial information.
Addressed to: Nottingham University Hospital NHS Trust
3 responses identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 14 Sep 2022
Added from Judiciary.uk 6 Oct 2022
Reference 2022-0286
Coroner: Alison Mutch
North West
Manchester South
AI-generated concerns summaryThe coroner noted a lack of clear mechanisms to inform Social Services of a vulnerable person's move and to ensure the quality of care provided in private arrangements, which led to her dropping out of sight of agencies.
Addressed to: Department of Health and Social Care
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 14 Sep 2022
Added from Judiciary.uk 5 Oct 2022
Reference 2022-0285
Coroner: Alison Mutch
North West
Manchester South
AI-generated concerns summaryThe coroner noted a prolonged A&E stay due to lack of bed capacity and delayed surgery beyond NICE guidelines, which significantly impacted the patient's physiological reserves and overall condition.
Addressed to: NHS England
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 14 Sep 2022
Added from Judiciary.uk 5 Oct 2022
Reference 2022-0284
Coroner: Alison Mutch
North West
Manchester South
AI-generated concerns summaryThe coroner noted extended waiting times for elective surgery due to COVID-19 backlogs, which affected Mrs Davies. Concerns were also raised about ongoing ambulance availability issues in Greater Manchester, leading to delayed urgent responses.
Addressed to: Department of Health and Social Care
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 14 Sep 2022
Added from Judiciary.uk 5 Oct 2022
Reference 2022-0283
Coroner: Paul Cooper
East Midlands
Lincolnshire
AI-generated concerns summaryThe coroner noted that no risk assessment was undertaken for the deceased's poor fluid intake upon admission to the care home, and omissions were made from the fluid intake chart. Policies and assessments for fluid and nutritional intake were not in place to cover this eventuality.
Addressed to: Tanglewood Cloverleaf Care Home
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 12 Sep 2022
Added from Judiciary.uk 5 Oct 2022
Reference 2022-0282
Coroner: Nicholas Rheinberg
North West
Lancashire with Blackburn and Darwen
AI-generated concerns summaryThe Trust did not have a protocol, policy, or adequate standard operating procedures in place to govern section 117 discharges.
Addressed to: Greater Manchester Mental Health NHS Foundation Trust
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 8 Sep 2022
Added from Judiciary.uk 5 Oct 2022
Reference 2022-0281
Coroner: Robert Simpson
South East
Hampshire, Portsmouth and Southampton
AI-generated concerns summaryThe coroner noted that the importance of checking the back of the throat for internal bleeding in patients with epistaxis or facial fractures was not widely known by staff in the Emergency Department and Trauma Admission Unit.
Addressed to: University Hospital Southampton NHS Foundation Trust
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 7 Sep 2022
Added from Judiciary.uk 5 Oct 2022
Reference 2022-0280
Coroner: Paul Cooper
East Midlands
Lincolnshire
AI-generated concerns summaryThe coroner noted concerns regarding the prescription of Rivaroxaban to a patient with liver impairment, low platelets, and impaired renal function, despite contraindications, which may have contributed to subsequent bleeding and cerebral haemorrhage.
Addressed to: United Lincolnshire Hospital
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 12 Sep 2022
Added from Judiciary.uk 5 Oct 2022
Reference 2022-0279
Coroner: Graeme Irvine
London
East London
AI-generated concerns summaryThe report notes a chaotic cardiac arrest response, failures to escalate high blood pressure, and no VTE risk assessment in line with policy. Additionally, an error regarding a DNACPR was not admitted to the family or other parties.
Addressed to: Department of Health and Social Care; East London NHS Foundation Trust
2 responses identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 20 Sep 2022
Added from Judiciary.uk 5 Oct 2022
Reference 2022-0278
Coroner: Joanne Andrews
South East
North East Kent
AI-generated concerns summaryThe coroner identified a lack of clarity regarding "carer breakdown" in mental health risk assessments and no process to contact carers on discharge when a Care Programme Approach is not in place.
Addressed to: Kent and Medway NHS Social Care Partnership Trust
0 responses identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 5 Sep 2022
Added from Judiciary.uk 5 Oct 2022
Reference 2022-0277
Coroner: Mary Hassell
London
Inner North London
AI-generated concerns summaryA patient was not placed on the multi-disciplinary team meeting board for discussion, leading to no follow-up despite reporting distress. The welfare check documentation was also found to be insufficient, and the Trust provided no evidence of preventative steps.
Addressed to: Camden and Islington NHS Foundation Trust
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 6 Sep 2022
Added from Judiciary.uk 5 Oct 2022
Reference 2022-0276
Coroner: Ian Arrow
South West
Plymouth, Torbay and South Devon
AI-generated concerns summaryThe coroner identified a missed opportunity to provide timely care and treatment to the deceased before she was found in extremis.
Addressed to: Devon NHS Integrated Care Commission
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 5 Sep 2022
Added from Judiciary.uk 4 Oct 2022
Reference 2022-0275
Coroner: Catherine McKenna
North West
Manchester North
AI-generated concerns summaryThe coroner identified insufficient availability of beds for informal admissions to older adults mental health wards and a lack of psychotherapy services for older adults in the community.
Addressed to: NHS Greater Manchester Integrated Care
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 5 Sep 2022
Added from Judiciary.uk 4 Oct 2022
Reference 2022-0274
Coroner: Karen Harrold
South East
West Sussex
AI-generated concerns summaryThe coroner raised concerns regarding communication failures between hospital Trusts, citing an outdated Service Level Agreement, the failure of informal referral 'workarounds' to replace formal inter-provider transfers for cancer patients, and inadequate use of electronic tracking systems.
Addressed to: NHS England, Royal Surrey County Hospital NHS Foundation Trust and Surrey and Sussex Healthcare NHS Trust
2 responses identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 2 Sep 2022
Added from Judiciary.uk 4 Oct 2022
Reference 2022-0273
Coroner: Catherine McKenna
North West
Manchester North
AI-generated concerns summaryThe coroner noted a gap in commissioning arrangements for dermatology services covering inpatients at Royal Oldham Hospital who are from outside the Oldham area, unless they become emergency dermatological cases.
Addressed to: NHS Greater Manchester Integrated Care
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 4 Sep 2022
Added from Judiciary.uk 4 Oct 2022
Reference 2022-0272
Coroner: Lydia Brown
London
West London
AI-generated concerns summaryThe coroner identified that a highly vulnerable ventilator-dependent child did not consistently receive prescribed 2:1 care, and the complex care package lacked appropriate review, quality checks, and escalation of parents' concerns.
Addressed to: Clinical Commissioning Group; NHS England
2 responses identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 5 May 2022
Added from Judiciary.uk 4 Oct 2022
Reference 2022-0271
Coroner: Joanne Lees
West Midlands
Black Country
AI-generated concerns summaryThe coroner noted an increased risk of fire or accident from unmaintained electrical equipment during the Covid-19 pandemic, with P3 failing to reassess these risks. There is no contingency plan for managing such risks in future lockdowns.
Addressed to: P3 Charity
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 31 Aug 2022
Added from Judiciary.uk 4 Oct 2022
Reference 2022-0270
Coroner: Caroline Saunders
Wales
Gwent
AI-generated concerns summaryThe coroner noted insufficient support for the individual, who was transferred between mental health and ENT teams that did not communicate directly, resulting in them falling between services.
Addressed to: Aneurin Bevan University Heath Board
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 31 Aug 2022
Added from Judiciary.uk 4 Oct 2022
Reference 2022-0269
Coroner: Paul Cooper
East Midlands
Lincolnshire
AI-generated concerns summaryThe coroner raised concerns about the decision not to charge the parents under the Children and Young Persons Act 1933, despite evidence of neglect, and requested the police to review the case file again.
Addressed to: Constable of Lincolnshire
0 responses identified · 1 indexed addressee. Read concerns and response evidence →