Report dated 31 Mar 2021
Added from Judiciary.uk 28 Jun 2021
Reference 2021-0204
Coroner: Alison Hewitt
London
City of London
AI-generated concerns summaryThe coroner notes that Public Health England's nationally recognised risk for Mycobacterium Chimaera infection is inaccurate, based on outdated 2017 data and underreporting, impacting informed consent and timely diagnosis. An immediate review and update of this statistical data is required.
Addressed to: College of Clinical Perfusion Scientists; National Institute for Cardiovascular Outcomes Research; Public Health England; Society for Cardiothoracic Surgery
1 response identified · 4 indexed addressees. Read concerns and response evidence →
Report dated 9 Jun 2021
Added from Judiciary.uk 28 Jun 2021
Reference 2021-0203
Coroner: Ian Arrow
South West
Plymouth Torbay and South Devon
AI-generated concerns summaryThe coroner highlighted the need for improved communication between Devon Partnership Trust staff and Children's Services to ensure appropriate support for parents with mental health problems during child protection investigations or care proceedings planning.
Addressed to: Devon Partnership Trust and Devon County Council
0 responses identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 14 Jun 2021
Added from Judiciary.uk 14 Jun 2021
Reference 2021-0202
Coroner: Alison Mutch
North West
Greater Manchester South
AI-generated concerns summaryThe coroner noted it was unclear how Amitriptyline was dispensed instead of Atenolol. Concerns were raised about the lack of clarity regarding pharmacy checks to prevent incorrect medication dispensing, particularly when medication is administered by non-clinically trained carers to vulnerable adults.
Addressed to: Medicines and Healthcare Products Regulatory Agency; NHS Stockport Clinical Commissioning Group
1 response identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 11 Jun 2021
Added from Judiciary.uk 14 Jun 2021
Reference 2021-0201
Coroner: Alison Mutch
North West
Greater Manchester South
AI-generated concerns summaryThe coroner noted GP surgeries in Tameside predominantly used telephone appointments, potentially delaying COVID-19 identification and treatment. Concerns were also raised regarding the clarity of processes for identifying high-risk COVID-19 cases or when to conduct additional assessments for vulnerable patients.
Addressed to: Tameside Clinical Commissioning Group
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 9 Jun 2021
Added from Judiciary.uk 14 Jun 2021
Reference 2021-0200
Coroner: Mary Burke
Yorkshire and the Humber
West Yorkshire Western Division
AI-generated concerns summaryThe coroner raised concerns regarding the absence of a psychiatric assessment for Mr Duhaney at Pinderfield's Hospital and a failure to follow discharge protocols when he self-discharged. There were also gaps in communication between the hospital and the community treatment team, leading to a delay in follow-up.
Addressed to: Mid Yorkshire Hospitals NHS Trust and South West Yorkshire Partnership NHS Trust
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 10 Jun 2021
Added from Judiciary.uk 14 Jun 2021
Reference 2021-0199
Coroner: Alison Mutch
North West
Manchester South
AI-generated concerns summaryThe coroner raised concerns that a vulnerable inpatient was not vaccinated for Covid-19 due to hospital policy and contracted the virus because of discharge delays. The discharge assessment framework did not adequately consider his vulnerability to rapid decline from Covid-19.
Addressed to: Department of Health and Social Care; NHS England
2 responses identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 10 Jun 2021
Added from Judiciary.uk 14 Jun 2021
Reference 2021-0198
Coroner: Chris Morris
North West
Manchester South
AI-generated concerns summaryThe coroner noted minimal regulation of miniature rifle ranges under the Firearms Act 1968. This raises concerns about absent safety requirements for user declarations, secure weapon handling, constant competent supervision, and appropriate first aid provisions.
Addressed to: Home Office
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 9 Jun 2021
Added from Judiciary.uk 14 Jun 2021
Reference 2021-0197
Coroner: Jason Pegg
South East
Hampshire, Portsmouth and Southhampton
AI-generated concerns summaryThe coroner noted concerns that a radio intercom device, attached to a helmet with an adhesive pad, did not detach when entangled with kite rigging, preventing the kite from being depowered. This concern also applies to other devices similarly affixed to helmets.
Addressed to: British Kite Surfing Association
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 8 Jun 2021
Added from Judiciary.uk 14 Jun 2021
Reference 2021-0196
Coroner: Alison Mutch
North West
Greater Manchester South
AI-generated concerns summaryConcerns included delays in addressing significant self-neglect and hoarding issues that posed a fire risk, despite agencies being aware. There was also poor inter-agency communication and no clear strategy to manage these identified risks.
Addressed to: Stockport Metropolitan Borough Council
0 responses identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 7 Jun 2021
Added from Judiciary.uk 14 Jun 2021
Reference 2021-0195
Coroner: Dr Anthony Howard
Yorkshire and the Humber
West Yorkshire Western Division
AI-generated concerns summaryThe coroner identified insufficient timely and effective handover between surgical specialties due to an absence of formal protocol. There were also concerns about the engagement of Plastic Surgeons during a theatre incident and a subsequent investigation.
Addressed to: Bradford Royal Infirmary
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 4 Jun 2021
Added from Judiciary.uk 14 Jun 2021
Reference 2021-0194
Coroner: Mary Hassell
London
Inner North London
AI-generated concerns summaryThe coroner highlighted that monitoring a discharged patient's relationship status, a key risk assessment condition, relied on his self-reporting despite known untruthfulness. No independent investigation mechanism existed, meaning unreliability was inherent in the system.
Addressed to: Ministry of Justice
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 4 Jun 2021
Added from Judiciary.uk 14 Jun 2021
Reference 2021-0193
Coroner: Penelope Schofield
South East
West Sussex
AI-generated concerns summaryThe junction between the Downs link and the A281 poses a substantial risk for users due to the lack of a safe crossing and poor sight lines. Although West Sussex County Council has identified these issues, definitive plans to address them are not yet in place.
Addressed to: West Sussex County Council
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 4 Jun 2021
Added from Judiciary.uk 4 Jun 2021
Reference 2021-0192
Coroner: Veronica Hamilton-Deeley
South East
City of Brighton and Hove
AI-generated concerns summaryThe coroner noted that the in-car radio should have been switched on at all times and the siren should have been deployed.
Addressed to: National Police Chiefs’ Council; Sussex Police
2 responses identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 4 Jun 2021
Added from Judiciary.uk 4 Jun 2021
Reference 2021-0191
Coroner: David Reid
West Midlands
Worcestershire
AI-generated concerns summaryThe coroner noted the absence of an effective system for social care referrals at HMP Long Lartin and issues with ACCT Case Manager allocation. This led to a lack of oversight for vulnerable individuals and inaccurate care map documentation.
Addressed to: HMP Long Lartin
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 2 Jun 2021
Added from Judiciary.uk 4 Jun 2021
Reference 2021-0190
Coroner: Alison Mutch
North West
Greater Manchester South
AI-generated concerns summaryThe coroner noted concerns regarding the prescribing of oxycodone and other medications to an individual with a history of addiction, especially when prescriptions were issued via telephone consultations and replacement prescriptions were given with little challenge.
Addressed to: Stockport Clinical Commissioning Group
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 2 Jun 2021
Added from Judiciary.uk 4 Jun 2021
Reference 2021-0189
Coroner: Tom Osborne
South East
Milton Keynes
AI-generated concerns summaryThe coroner noted that a prisoner's release date was not calculated until after their recall, leading to unlawful detention. A process is required to calculate release dates before a recall decision to prevent similar unlawful imprisonments.
Addressed to: Ministry of Justice
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 2 Jun 2021
Added from Judiciary.uk 4 Jun 2021
Reference 2021-0188
Coroner: Bina Patel
South East
Mid Kent and Medway
AI-generated concerns summaryA patient's risk assessment was not completed within 24 hours of admission to Elvy Court Nursing Home, and staff did not identify this oversight. The home lacked an adequate process for auditing the completion of such assessments according to its policy.
Addressed to: Avery Healthcare; Elvy Court Nursing Home
1 response identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 1 Jun 2021
Added from Judiciary.uk 4 Jun 2021
Reference 2021-0187
Coroner: Samantha Marsh
South East
Hampshire, Portsmouth and Southampton
AI-generated concerns summaryThe coroner identified a lack of sufficient training and appropriate tools for staff to respond to a resident found suspended. Additionally, concerns were raised regarding ineffective policy communication, which meant staff did not consistently read or understand crucial updates.
Addressed to: A2Dominion of The Point
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 28 May 2021
Added from Judiciary.uk 2 Jun 2021
Reference 2021-0186
Coroner: Nicholas Moss QC
East of England
Cambridgeshire and Peterborough
AI-generated concerns summaryThe coroner raises concerns about the lack of national guidance for pharmacies to be involved in medication safety plans for mental health patients aged 16-17, noting this poses a risk of future fatalities.
Addressed to: Company Chemists’ Association; General Pharmaceutical Council; NHS England; Royal Pharmaceutical Society
4 responses identified · 4 indexed addressees. Read concerns and response evidence →
Report dated 28 May 2021
Added from Judiciary.uk 2 Jun 2021
Reference 2021-0185
Coroner: Nicholas Moss QC
East of England
Cambridgeshire and Peterborough
AI-generated concerns summaryThe coroner noted that investigations into railway deaths should keep an open mind regarding potential access routes, as a failure to do so risks missing opportunities for mitigating measures to prevent future fatalities.
Addressed to: British Transport Police; Network Rail
2 responses identified · 2 indexed addressees. Read concerns and response evidence →