Added from Judiciary.uk 2 Jun 2021
Reference 2021-0184
Coroner: Nicholas Moss QC
East of England
Cambridgeshire and Peterborough
AI-generated concerns summaryThe coroner noted a lack of follow-up between police and clinicians or parents regarding young victims with mental ill health to keep open the option of providing an evidential account. There was also no guidance for police on communicating with such victims who are initially unwilling to provide a statement.
Addressed to: Cambridgeshire and Peterborough Foundation Trust (CPFT); Cambridgeshire County Council (CCC); The National Police Chiefs' Council
3 responses identified · 3 indexed addressees. Read concerns and response evidence →
Report dated 28 May 2021
Added from Judiciary.uk 2 Jun 2021
Reference 2021-0183
Coroner: Catherine McKenna
North West
Manchester North
AI-generated concerns summaryThe Trust has no formal guidance for Consultant Psychiatrists, other healthcare professionals, or family members to seek second opinions on diagnosis, treatment, or detention criteria. There is also a lack of understanding among in-patient Consultants regarding confidentiality rules when communicating with family members.
Addressed to: Pennine Care NHS Foundation Trust
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 28 May 2021
Added from Judiciary.uk 2 Jun 2021
Reference 2021-0182
Coroner: Jacqueline Lake
East of England
Norfolk
AI-generated concerns summaryThe coroner noted staff transporting the patient did not recognise deterioration or call emergency services immediately, and that only one of three staff was CPR trained, contrary to policy. An internal investigation did not identify these issues.
Addressed to: Premier Rescue Ambulance Services
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 27 May 2021
Added from Judiciary.uk 28 May 2021
Reference 2021-0181
Coroner: Joanne Kearsley
North West
Manchester North
AI-generated concerns summaryGMP officers lacked understanding of ACT markers, causing delays in vehicle marking for missing person investigations. The national ANPR notification system also lacks full implementation across all forces.
Addressed to: Greater Manchester Police; National Police Chiefs Council
1 response identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 22 Apr 2021
Added from Judiciary.uk 27 May 2021
Reference 2021-0180
Coroner: Tom Osborne
South East
Milton Keynes
AI-generated concerns summaryThe coroner identified a lack of mental health support available to prison officers and recommended a review of its provision.
Addressed to: Minister of State for Prisons
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 25 May 2021
Added from Judiciary.uk 27 May 2021
Reference 2021-0179
Coroner: Ian Brownhill
South East
Mid Kent and Medway
AI-generated concerns summaryThe coroner identified a lack of direct telephone access for prisoners to contact Samaritans, particularly for violent individuals. Prison Officers are also not routinely briefed on prisoners' significant self-harm history or antecedent patterns.
Addressed to: HMP Elmley and Director General – Prisons
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 14 Apr 2021
Added from Judiciary.uk 27 May 2021
Reference 2021-0178
Coroner: Joanne Kearsley
North West
Manchester North
AI-generated concerns summaryThe care home's decision not to use pendant call alarms meant fixed call bells were inaccessible to residents at risk of falls when needed.
Addressed to: Rochcare
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 25 May 2021
Added from Judiciary.uk 27 May 2021
Reference 2021-0177
Coroner: Alan Blunsdon
South East
North West Kent
AI-generated concerns summaryInadequate training on a mobile phone location software update led to an incorrect call downgrade. The coroner also noted knowledge gaps among control room staff regarding suicide policy and call downgrading, and an unstructured training system.
Addressed to: Independent Office for Police Conduct; Kent Police
1 response identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 25 May 2021
Added from Judiciary.uk 27 May 2021
Reference 2021-0176
Coroner: Guy Davies
South West
Cornwall and the Isles of Scilly
AI-generated concerns summaryThe coroner noted converging surface water on the A390 during heavy rainfall, likely contributing to the incident. Drainage improvements to diminish aquaplaning risks at this location have not been implemented, despite a prior similar incident.
Addressed to: Cornwall Council and CORMAC
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 25 May 2021
Added from Judiciary.uk 27 May 2021
Reference 2021-0175
Coroner: Paul Smith
East Midlands
Lincolnshire
AI-generated concerns summaryThe coroner noted that a fixed screen monitor in the crop sprayer's cab created a significant blind-spot, obstructing the driver's view and contributing to the incident, despite having no function while the vehicle was being driven on the public highway.
Addressed to: Driver and Vehicle Licensing Agency
0 responses identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 12 Feb 2021
Added from Judiciary.uk 27 May 2021
Reference 2021-0174
Coroner: Gemma Brannigan
South East
Oxfordshire
AI-generated concerns summaryThe Major Trauma Centre lacks a major trauma lead consultant and a trauma co-ordinator, which are expected posts under NICE guidelines, and this has been the position since at least 2018.
Addressed to: Oxford University Hospitals NHS Foundation Trust
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 19 Feb 2021
Added from Judiciary.uk 27 May 2021
Reference 2021-0173
Coroner: Darren Salter
South East
Oxfordshire
AI-generated concerns summaryDespite improved signage and reduced speed limits, the coroner noted a continued danger of drivers not noticing a roundabout in sufficient time due to its approach around a bend. Consideration of further engineering, such as rumble strips, was suggested to provide an auditory warning.
Addressed to: Oxfordshire County Council
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 15 Dec 2020
Added from Judiciary.uk 27 May 2021
Reference 2021-0172
Coroner: Darren Salter
South East
Oxfordshire
AI-generated concerns summaryThe coroner identified challenges in reliably confirming NG tube placement in infants, particularly with pH testing when medication is used and limiting X-ray exposure. Concerns also included staff misunderstanding individualised policy adjustments.
Addressed to: Oxford University Hospitals NHS Foundation Trust
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 10 Feb 2021
Added from Judiciary.uk 27 May 2021
Reference 2021-0171
Coroner: Sonia Hayes
South East
Oxfordshire
AI-generated concerns summaryThe coroner noted a lack of a clear care plan following an emergency review and that care plans and risk assessments were not updated with material information regarding multiple overdoses and new clinical disclosures.
Addressed to: Oxford Health NHS Trust
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 24 May 2021
Added from Judiciary.uk 27 May 2021
Reference 2021-0170
Coroner: Timothy Brennand
North West
Manchester West
AI-generated concerns summaryThe coroner identified an suboptimal decision to reduce supervision without a review date, a lack of further falls risk assessments after multiple falls, and insufficient consideration of medication changes. There was also delayed escalation of clinical concerns.
Addressed to: Bolton Council Commissioning Services; NHS Bolton Clinical Commissioning Group; Shannon Court Care Centre
0 responses identified · 3 indexed addressees. Read concerns and response evidence →
Report dated 28 May 2021
Added from Judiciary.uk 27 May 2021
Reference 2021-0169
Coroner: Veronica Hamilton-Deeley
South East
City of Brighton and Hove
AI-generated concerns summaryThe coroner identified an almost complete reliance on assumed capacity, a failure to assess or understand the impact of Mr Fitton's Acquired Brain Injury, and poor communication between teams. Staff lacked adequate training in ABI and relevant legislation.
Addressed to: Brighton and Hove Clinical Commissioning Group; Brighton and Hove Council; Brighton and Hove Health and Adult Social Care; Sussex Police
1 response identified · 4 indexed addressees. Read concerns and response evidence →
Report dated 24 May 2021
Added from Judiciary.uk 24 May 2021
Reference 2021-0168
Coroner: Alison Mutch
North West
Manchester South
AI-generated concerns summaryThe coroner identified issues with the clarity of scan reporting and recording, which meant the treating clinician did not appreciate the findings. There was also insufficient documentation of clinical decisions, especially when not following specialist advice, and no clear guidance on recording such rationales.
Addressed to: Tameside & Glossop Integrated Care NHS Foundation Trust
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 21 May 2021
Added from Judiciary.uk 24 May 2021
Reference 2021-0167
Coroner: Zak Golombeck
North West
Manchester City
AI-generated concerns summaryThe EMIS system for repeat prescriptions does not provide automated alerts to remind patients, particularly those with mental illness, to request and collect their medication. This feature could encourage compliance without increasing staff workload.
Addressed to: EMIS Health; National Institute for Health and Care Excellence; Royal College of GPs
4 responses identified · 3 indexed addressees. Read concerns and response evidence →
Report dated 21 May 2021
Added from Judiciary.uk 24 May 2021
Reference 2021-0166
Coroner: Alison Mutch
North West
Manchester South
AI-generated concerns summaryThe coroner noted gaps in shared risk assessment definitions and care planning guidance between acute and mental health trusts. Delays in accessing a mental health bed were also raised, attributed to national bed shortages and commissioning structures.
Addressed to: Department of Health and Social Care; Greater Manchester Health and Social Care Partnership
2 responses identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 20 May 2021
Added from Judiciary.uk 24 May 2021
Reference 2021-0165
Coroner: Brendan Allen
South West
County of Dorset
AI-generated concerns summaryThe coroner noted the absence of a barrier between the highway and a storm drain at the A338 Blackwater Junction exit, which creates a risk of cyclists or vehicles falling into the drain.
Addressed to: BCP Council
1 response identified · 1 indexed addressee. Read concerns and response evidence →