Report dated 28 Aug 2020
Added from Judiciary.uk 26 Oct 2020
Reference 2020-0167
Coroner: Timothy Brennand
East Midlands
Lincolnshire
AI-generated concerns summaryConcerns included 'confirmation bias' among discipline and healthcare staff when assessing detainees presumed to be under the influence of drugs, leading to inadequate verification and clinical evaluation. The report also identified insufficient staff training on new psychoactive substances and a lack of clear communication and escalation protocols for drug-related incidents …
Addressed to: Morton Hall Immigration Removal Centre; Nottingham Healthcare NHS Foundation Trust
0 responses identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 25 Aug 2020
Added from Judiciary.uk 26 Oct 2020
Reference 2020-0166
Coroner: M E Hassell
London
Inner North London
AI-generated concerns summaryThe coroner noted that Mr. Coleman was living unnoticed on a demolition site by managers and security, alongside concerns about inconsistent security patrols and incomplete site records. The report also highlighted an insufficient drug and alcohol risk assessment for individuals managing sites.
Addressed to: Camden Council; First Response Group
1 response identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 27 Aug 2020
Added from Judiciary.uk 26 Oct 2020
Reference 2020-0165
Coroner: Alan Wilson
North West
Blackpool & Fylde
AI-generated concerns summaryThe coroner noted insufficient staff response to a fall by a dementia patient unable to communicate symptoms, and raised concerns about the inaccurate and unreliable quality of nursing home record-keeping.
Addressed to: Rossendale Nursing Home
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 26 Aug 2020
Added from Judiciary.uk 26 Oct 2020
Reference 2020-0164
Coroner: Timothy Brennand
East Midlands
Lincolnshire
AI-generated concerns summaryThe coroner identified insufficient coordination and management of a patient with a complex dual diagnosis, lacking a structured care programme, assertive outreach, and a dedicated drug and alcohol recovery team, leading to missed opportunities for assessment.
Addressed to: Lincolnshire County Council; Lincolnshire Partnership NHS Foundation Trust; South Lincolnshire Clinical Commissioning Group; We Are With You charity
3 responses identified · 4 indexed addressees. Read concerns and response evidence →
Report dated 18 Aug 2020
Added from Judiciary.uk 26 Oct 2020
Reference 2020-0163
Coroner: Oliver Longstaff
North East
County Durham and Darlington
AI-generated concerns summaryThe coroner identified that Mr Scott-Brown was not given information on Lamotrigine's potential side effect of self-harm or suicidal thoughts. There are also inconsistencies regarding this significant side effect across different pharmacological resources, posing a potential risk to patients.
Addressed to: Informa Healthcare; National Institute for Health and Care Excellence; Oxleas NHS Foundation Trust; South London and Maudsley NHS Foundation Trust; Tees, Esk and Wear Valleys NHS Foundation Trust
4 responses identified · 5 indexed addressees. Read concerns and response evidence →
Report dated 21 Aug 2020
Added from Judiciary.uk 26 Oct 2020
Reference 2020-0162
Coroner: M E Hassell
London
Inner North London
AI-generated concerns summaryThe Royal Free Hospital has not shared national learning about the increased risk of uterine rupture in multi-gravida mothers. Additionally, the lack of computers in the delivery suite hindered midwives from contemporaneous observation recording.
Addressed to: Royal Free Hospital
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 17 Aug 2020
Added from Judiciary.uk 26 Oct 2020
Reference 2020-0161
Coroner: Louise Hunt
West Midlands
Birmingham and Solihull
AI-generated concerns summaryThe coroner identified that a high clozapine level in Mr Allen's blood was not acted upon, with no system in place to escalate such results to a consultant. Concerns were also raised about a general lack of understanding among mental health practitioners regarding clozapine monitoring and the need for national …
Addressed to: Birmingham and Solihull Mental Health Foundation Trust; Department of Health and Social Care
2 responses identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 11 Aug 2020
Added from Judiciary.uk 22 Oct 2020
Reference 2020-0160
Coroner: Graeme Irvine
London
East London
AI-generated concerns summaryConcerns include inadequate computerised records for patient address changes and a lack of safeguards for discharging vulnerable patients to the correct address. Additionally, the report identifies insufficient monitoring of 'fed at risk' patients and a failure to commence CPR despite a potentially reversible cause.
Addressed to: Barts Health NHS Trust; London Borough of Tower Hamlets; Three Sisters Care Ltd
2 responses identified · 3 indexed addressees. Read concerns and response evidence →
Report dated 14 Aug 2020
Added from Judiciary.uk 22 Oct 2020
Reference 2020-0159
Coroner: Penelope Schofield
South East
West Sussex
AI-generated concerns summaryThe coroner raised concerns about the lack of communication to out-of-area hospital patients regarding a Listeria outbreak, which delayed diagnosis. They also noted no legal requirement for private labs or hospitals to share Listeria isolates, impeding early outbreak identification.
Addressed to: NHS England; Public Health England
1 response identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 6 Aug 2020
Added from Judiciary.uk 22 Oct 2020
Reference 2020-0158
Coroner: Graeme Irvine
London
East London
AI-generated concerns summaryThe surgery lacked documentary records of critical telephone calls and a consultation regarding a high-risk patient's prescription. A doctor acted outside surgery guidance for prescription length, and no audit was undertaken to identify other similar instances.
Addressed to: Rush Green Medical Centre
0 responses identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 4 Jun 2020
Added from Judiciary.uk 22 Oct 2020
Reference 2020-0157
Coroner: Alison Mutch
North West
Greater Manchester South
AI-generated concerns summaryThe coroner noted insufficient GPs, an unclear nurse-to-doctor escalation process, and poor medical notes at the GP practice, which meant the patient's specific health risks were not recognised.
Addressed to: NHS Trafford Clinical Commissioning Group
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 11 Aug 2020
Added from Judiciary.uk 21 Oct 2020
Reference 2020-0156
Coroner: Chris Morris
North West
Greater Manchester South
AI-generated concerns summaryThe Trust did not conduct a formal Serious Untoward Incident investigation into Mrs Scully's care, and its Emergency Department lacked a Rapid Assessment and Treatment Model for walk-in patients.
Addressed to: Royal College of Radiologists; Tameside and Glossop Integrated Care NHS Foundation Trust
2 responses identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 23 Apr 2020
Added from Judiciary.uk 20 Oct 2020
Reference 2020-0155
Coroner: Gordon Clow
East Midlands
Nottinghamshire & Nottingham
AI-generated concerns summaryCommunity Mental Health Teams in Nottinghamshire have insufficient clinical psychologist staffing, with many teams having only one or part-time roles, leading to patients lacking access to clinically indicated psychological support, contrary to guidance.
Addressed to: Bassetlaw Clinical Commissioning Group; Mansfield and Ashfield Clinical Commissioning Group; Newark and Sherwood Clinical Commissioning Group; Nottingham City Clinical Commissioning Group; Nottingham North and East Clinical Commissioning Group; Nottingham West Clinical Commissioning Group; Rushcliffe Clinical Commissioning Group
2 responses identified · 7 indexed addressees. Read concerns and response evidence →
Report dated 10 Aug 2020
Added from Judiciary.uk 19 Oct 2020
Reference 2020-0154
Coroner: Emma Brown
West Midlands
Birmingham & Solihull
AI-generated concerns summaryThe coroner noted a communication gap where changes to medication for a patient with cognitive impairment were not directly conveyed to his next of kin, causing confusion. There are concerns that the hospital may not formally implement a procedure for such communications or conduct a broader investigation.
Addressed to: University Hospitals Birmingham NHS Foundation Trust
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 7 Aug 2020
Added from Judiciary.uk 19 Oct 2020
Reference 2020-0153
Coroner: Andrew Cox
South West
Cornwall & Isles of Scilly
AI-generated concerns summaryThe coroner raised concerns regarding the adequacy of coastguard and lifeguard cover around the Cornish coastline. This included enquiring about potential reductions due to the pandemic, how any shortfalls are mitigated, and if public plans are published.
Addressed to: Maritime Coastguard Agency; Royal National Lifeboat Institution
2 responses identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 7 Aug 2020
Added from Judiciary.uk 19 Oct 2020
Reference 2020-0152
Coroner: Andrew Cox
South West
Cornwall & Isles of Scilly
AI-generated concerns summaryThe coroner notes reduced lifeguard cover on Cornish beaches compared to 2019 levels and identifies a lack of a clear, publicised plan detailing lifeguard provision and mitigation strategies for reduced service.
Addressed to: Maritime Coastguard Agency; Royal National Lifeboat Institution
2 responses identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 5 Aug 2020
Added from Judiciary.uk 19 Oct 2020
Reference 2020-0151
Coroner: Tom Osborne
South East
Milton Keynes
AI-generated concerns summaryThe drug information leaflet for doxycycline did not mention the possibility of a psychotic reaction, which the coroner suggests could have allowed earlier intervention.
Addressed to: Medicines and Healthcare Products Regulatory Agency
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 5 Aug 2020
Added from Judiciary.uk 16 Oct 2020
Reference 2020-0150
Coroner: Tom Osborne
South East
Milton Keynes
AI-generated concerns summaryThe coroner noted that the attending paramedic did not follow recognised protocols, and the existing procedure requires review to ensure seriously ill patients are transferred to hospital for assessment.
Addressed to: South Central Ambulance Service
0 responses identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 4 Aug 2020
Added from Judiciary.uk 16 Oct 2020
Reference 2020-0149
Coroner: Yvonne Blake
East of England
Norfolk
AI-generated concerns summaryThe coroner noted that the patient's ability to read was not checked upon admission or discharge, which could impact understanding of vital instructions. Despite the death, the hospital had not introduced procedures to ascertain patient literacy after eight months.
Addressed to: James Paget University Hospital
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 6 Jul 2020
Added from Judiciary.uk 9 Oct 2020
Reference 2020-0148
Coroner: Chinyere Inyama
London
West London
AI-generated concerns summaryThe coroner noted a need for clearer guidance for CNWL staff on when to refer cases to healthcare, beyond knowing the referral process. Concerns were also raised about the Independent Monitoring Board not simultaneously reporting detainee concerns to IRC healthcare managers.
Addressed to: Central & North West London NHS Foundation Trust; Independent Monitoring Board
2 responses identified · 2 indexed addressees. Read concerns and response evidence →