Report dated 29 Sep 2020
Added from Judiciary.uk 23 Nov 2020
Reference 2020-0187
Coroner: Caroline Beasley-Murray
East of England
Essex
AI-generated concerns summaryThe coroner raised concerns regarding the automatic category 3 classification of abandoned calls and calls reporting medical conditions. There was also a concern that the duty EOC did not listen to call recordings or receive full medical details when considering upgrades.
Addressed to: AACE’s National Directors of Operations Group; Association of Ambulance Chief Executives; Emergency Call Prioritisation Advisory Group; National Association of Ambulance Medical Directors
1 response identified · 4 indexed addressees. Read concerns and response evidence →
Report dated 28 Sep 2020
Added from Judiciary.uk 23 Nov 2020
Reference 2020-0186
Coroner: Lincoln Brookes
East of England
Essex
AI-generated concerns summaryThe coroner noted staff unfamiliarity with national and outdated hospital morphine guidelines, which also conflicted with current best practices. Concerns were raised about insufficient education for doctors and communication breakdowns hindering nurses from challenging unsafe prescriptions.
Addressed to: East Suffolk and North Essex NHS Foundation Trust
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 28 Sep 2020
Added from Judiciary.uk 19 Nov 2020
Reference 2020-0185
Coroner: Chris Morris
North West
Greater Manchester South
AI-generated concerns summaryThe coroner identified insufficient 'tick-box' checks for bed safety in nursing documentation, alongside a lack of guidance for clinical incident investigations. Concerns also included a lack of organisational candour and gaps in inter-hospital information sharing.
Addressed to: Care Quality Commission; Department of Health and Social Care; Manchester University Hospitals NHS Foundation Trust; NHS England
4 responses identified · 4 indexed addressees. Read concerns and response evidence →
Report dated 25 Sep 2020
Added from Judiciary.uk 19 Nov 2020
Reference 2020-0184
Coroner: Nadia Persaud
London
East London
AI-generated concerns summaryThe coroner noted a significant number of deaths from DNP toxicity, particularly affecting young individuals. Concerns were raised that current legislation is considered inadequate to prevent its sale, and it remains readily available online without sufficient internet protections.
Addressed to: Home Office
0 responses identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 24 Sep 2020
Added from Judiciary.uk 19 Nov 2020
Reference 2020-0183
Coroner: Kevin McLoughlin
Yorkshire and the Humber
West Yorkshire (East)
AI-generated concerns summaryThe urgent referral system within Adult Social Care was ineffective, leading to no contact with a vulnerable individual. Additionally, there was no safety net for ambulance referral if the Adult Social Care team could not respond promptly.
Addressed to: Health and Communities Wakefield
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 23 Sep 2020
Added from Judiciary.uk 19 Nov 2020
Reference 2020-0182
Coroner: Colin Phillips
Wales
Swansea and Neath Port Talbot
AI-generated concerns summaryThe coroner questioned the appropriateness of grading stroke patients in the 'amber' category and suggested setting specific time targets for treatment, with additional resources for WAST, to ensure timely thrombolysis.
Addressed to: Department of Health and Social Care; Welsh Ambulance Services NHS Trust
2 responses identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 23 Sep 2020
Added from Judiciary.uk 19 Nov 2020
Reference 2020-0181
Coroner: Emma Serrano
East Midlands
Derby and Derbyshire
AI-generated concerns summaryWhen patients register at new GP surgeries, their medical notes and history are often delayed in transfer, resulting in doctors treating and prescribing without access to a complete medical record.
Addressed to: NHS Derby & Derbyshire Clinical Commissioning Group; NHS England; Primary Care Support England
1 response identified · 3 indexed addressees. Read concerns and response evidence →
Report dated 23 Sep 2020
Added from Judiciary.uk 19 Nov 2020
Reference 2020-0180
Coroner: Nadia Persaud
London
East London
AI-generated concerns summaryThe coroner raised concerns regarding the absence of a statutory procedure for international criminal conviction checks, which could lead to unsuitable individuals working with vulnerable adults and children.
Addressed to: Disclosure and Barring Service
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 23 Sep 2020
Added from Judiciary.uk 19 Nov 2020
Reference 2020-0179
Coroner: Nicholas Rheinberg
North West
Lancashire and Blackburn with Darwen
AI-generated concerns summaryThe coroner noted insufficient first-aid and resuscitation training for some long-serving prison officers, with no fixed completion date for refresher training. There were also concerns about inconsistent welfare checks by officers during morning cell unlocks, despite management reminders.
Addressed to: HMP Wymott
0 responses identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 21 Sep 2020
Added from Judiciary.uk 19 Nov 2020
Reference 2020-0178
Coroner: Ian Arrow
South West
Plymouth, Torbay and South Devon
AI-generated concerns summaryThe coroner noted an incomplete understanding of the patient's medical condition, due to unavailable full patient records, led to an incorrect choice of monitoring and anaesthetic. This identified gaps in the process for obtaining and reviewing medical records before planned anaesthesia.
Addressed to: Derriford Hospital
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 18 Sep 2020
Added from Judiciary.uk 19 Nov 2020
Reference 2020-0177
Coroner: Kevin McLoughlin
Yorkshire and the Humber
West Yorkshire (East)
AI-generated concerns summaryThe Trust was unaware of the deceased's medical conditions, leading to work on wards with multi-resistant organisms, and there was scant evidence of appropriate PPE training for agency staff. Nursing agencies supplied support workers without knowledge of their health vulnerabilities, creating infection risks for staff and patients.
Addressed to: Leeds Teaching Hospitals NHS Trust; Reed Nursing Trust
3 responses identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 14 Sep 2020
Added from Judiciary.uk 16 Nov 2020
Reference 2020-0176
Coroner: Sonia Hayes
South East
Central and South East Kent
AI-generated concerns summaryThe coroner identified a hazardous area in Victoria Park, Ashford, with a gap and sloped surface near a footbridge that poses a danger, especially at night. Responsibility for this area is unclear between Ashford Borough Council and Kent County Council.
Addressed to: Ashford Borough Council; Kent County Council
0 responses identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 18 Sep 2020
Added from Judiciary.uk 16 Nov 2020
Reference 2020-0175
Coroner: Kevin McLoughlin
Yorkshire and the Humber
West Yorkshire (East)
AI-generated concerns summaryThe coroner identified concerns regarding websites that promote methods of suicide to vulnerable individuals, potentially undermining treatment and legitimising self-harm. There were also concerns about the availability and promotion of lethal substances for ending one's life.
Addressed to: Department of Health and Social Care
0 responses identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 14 Sep 2020
Added from Judiciary.uk 16 Nov 2020
Reference 2020-0174
Coroner: Alan Wilson
North West
Blackpool & Fylde
AI-generated concerns summaryThe coroner identified that some parents do not appreciate or follow guidance on safe sleeping practices for young infants, particularly regarding co-sleeping and awareness of associated risks, despite efforts to provide advice.
Addressed to: Department of Health and Social Care
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 9 Sep 2020
Added from Judiciary.uk 16 Nov 2020
Reference 2020-0173
Coroner: Caroline Beasley-Murray
East of England
Essex
AI-generated concerns summaryThe coroner identified a lack of risk assessment for delivery options and insufficient training regarding forceps delivery for occipito-posterior position, with implied excessive force. Further concerns related to locum staff management, communication, record keeping, and resuscitation equipment.
Addressed to: Mid and South Essex NHS Foundation Trust
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 8 Sep 2020
Added from Judiciary.uk 10 Nov 2020
Reference 2020-0172
Coroner: Veronica Hamilton-Deeley
South East
Brighton and Hove
AI-generated concerns summaryThe coroner noted delays in applying an external fixator and an apparent failure to mobilise the patient.
Addressed to: Western Sussex Hospital Trust
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 8 Sep 2020
Added from Judiciary.uk 10 Nov 2020
Reference 2020-0171
Coroner: Chris Morris
North West
Greater Manchester South
AI-generated concerns summaryBorough Care did not investigate the circumstances of a resident's fall that led to his hospital admission. The coroner noted that robust investigations into falls are essential for learning and reducing the risk of future deaths.
Addressed to: Borough Care
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 3 Sep 2020
Added from Judiciary.uk 10 Nov 2020
Reference 2020-0170
Coroner: James Thompson
North East
County Durham & Darlington
AI-generated concerns summaryThe electronic system for repeat prescriptions allowed liquid morphine to be issued without further scrutiny, failing to prompt prescribers to review the patient's medical records where a previous overdose was recorded.
Addressed to: Department of Health and Social Care
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 7 Sep 2020
Added from Judiciary.uk 10 Nov 2020
Reference 2020-0169
Coroner: Nadia Persaud
London
East London
AI-generated concerns summaryThe coroner noted obstructions to driver views at a Pelican crossing, its placement after a bend with a speed limit change, and high non-compliance with traffic signals, raising a risk of future deaths.
Addressed to: Havering Highways
2 responses identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 4 Sep 2020
Added from Judiciary.uk 10 Nov 2020
Reference 2020-0168
Coroner: Adrian Farrow
North West
South Manchester
AI-generated concerns summaryThe coroner raised concerns that a Healthcare Safety Investigation Branch recommendation to add 'aortic pain' to the Manchester Triage System, intended to improve awareness and diagnosis of acute aortic dissection, has not been implemented.
Addressed to: National Institute for Health and Care Excellence
1 response identified · 1 indexed addressee. Read concerns and response evidence →