Report dated 24 Nov 2016
Added from Judiciary.uk 19 Feb 2017
Reference 2016-0421
Coroner: Louise Hunt
West Midlands
Birmingham and Solihull
AI-generated concerns summaryThe coroner identified gaps in record-keeping and communication processes regarding home visit requests between the GP and residential home, including clinical assessments being misclassified as "admin tasks." Concerns were also raised about the lack of GP clinical assessment for a deteriorating patient, the suitability of the home visit policy for …
Addressed to: Bright and Hove Clinical Commissioning Group; Pavillions; Richmond Medical Centre; Sussex Partnership NHS Trust
1 response identified · 4 indexed addressees. Read concerns and response evidence →
Report dated 29 Nov 2016
Added from Judiciary.uk 19 Feb 2017
Reference 2016-0422
Coroner: Emma Brown
West Midlands
Birmingham and Solihull
AI-generated concerns summaryThe coroner identified deficiencies in paramedic foundation training, noting a lack of formal testing on 12-lead ECG interpretation and awareness of atypical myocardial infarction signs.
Addressed to: Health and Care Professions Council
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 30 Nov 2016
Added from Judiciary.uk 19 Feb 2017
Reference 2016-0424
Coroner: Karen Henderson
South East
Surrey
AI-generated concerns summaryThe coroner noted concerns about the potential for multiple psychotropic medications to prolong the QT interval, highlighting the importance of pre-treatment and regular ECGs to monitor for long QT syndrome.
Addressed to: General Practitioners; Medicines and Healthcare products Regulatory Agency; Royal College of Psychiatrists; Department of Health
2 responses identified · 3 indexed addressees. Read concerns and response evidence →
Report dated 29 Nov 2016
Added from Judiciary.uk 19 Feb 2017
Reference 2016-0425
Coroner: Emma Carlyon
South West
Cornwall and Isles of Scilly
AI-generated concerns summaryThe coroner noted difficulties in providing supportive treatment for alcohol abusers on the Isles of Scilly due to limited face-to-face support. This was exacerbated by reduced transport services, making it challenging for professionals to travel and engage with service users.
Addressed to: Addaction; Drug and Alcohol Action Team; Cornwall Council; St Mary’s Health Centre
2 responses identified · 4 indexed addressees. Read concerns and response evidence →
Report dated 30 Nov 2016
Added from Judiciary.uk 19 Feb 2017
Reference 2016-0426
Coroner: Geraint Williams
West Midlands
Worcestershire
AI-generated concerns summaryConcerns were raised that the out-of-hours telephone number provided for suicidal ideation might be inaccessible to individuals with limited finances due to call charges. The coroner suggested that crisis telephone numbers should be freephone numbers.
Addressed to: Worcestershire Health and Care NHS Trust
0 responses identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 23 Nov 2016
Added from Judiciary.uk 19 Feb 2017
Reference 2016-0427
Coroner: Rachael Griffin
North West
Manchester (West)
AI-generated concerns summaryConcerns were raised regarding inadequate communication between Surgical and Coronary Care teams for patients under shared care, and the absence of a clear Trust policy to manage this interaction.
Addressed to: Warrington, Wigan and Leigh NHS Trust
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 18 Jan 2017
Added from Judiciary.uk 19 Feb 2017
Reference 2017-0026
Coroner: Heidi Connor
East Midlands
Nottinghamshire
AI-generated concerns summaryThe coroner identified concerns regarding the absence of a clear pathway for referral for life-saving neurosurgery, alongside issues with diagnostic imaging and the input from stroke physicians in appropriate cases.
Addressed to: Derby and Burton Hospitals; National Institute for Clinical Excellence; NHS England; Nottingham University Hospitals NHS Trust; Sheffield Teaching Hospitals NHS Trust
3 responses identified · 5 indexed addressees. Read concerns and response evidence →
Report dated 18 Jan 2017
Added from Judiciary.uk 19 Feb 2017
Reference 2017-0025
Coroner: David Roberts
North West
Cumbria
AI-generated concerns summaryThe coroner noted recurring deaths from misplaced nasogastric tubes, citing staff non-adherence to policy, inadequate training, and the Trust's failure to address prior issues. Concerns were also raised about the lengthy and error-prone policy document.
Addressed to: Department of Health and Social Care; North Cumbria University NHS Trust: NHS England
2 responses identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 18 Jan 2017
Added from Judiciary.uk 19 Feb 2017
Reference 2017-0024
Coroner: David Roberts
North West
Cumbria
AI-generated concerns summaryThe coroner noted multiple avoidable deaths from misplaced nasogastric tubes, linked to staff non-compliance with policy, inadequate training, and insufficient audits. Concerns also included the Trust's failure to learn from prior incidents and implement national alerts.
Addressed to: Department of Health and Social Care; North Cumbria University NHS Trust: NHS England
2 responses identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 25 Jan 2017
Added from Judiciary.uk 19 Feb 2017
Reference 2017-0023
Coroner: Veronica Hamilton-Deeley
South East
Brighton and Hove
AI-generated concerns summaryA poorly informed decision was made to discharge a patient without significant improvement in their condition, and the patient was not seen or reviewed by a doctor prior to discharge.
Addressed to: Brighton and Sussex University Hospitals NHS Trust
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 25 Jan 2017
Added from Judiciary.uk 19 Feb 2017
Reference 2017-0022
Coroner: Anna Crawford
South East
Surrey
AI-generated concerns summaryThe coroner noted insufficient staff knowledge regarding the BUPA choking policy and an inadequate understanding of when life-sustaining treatment should be provided to individuals with a DNAR order.
Addressed to: Collingwood Nursing Home
0 responses identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 30 Jan 2017
Added from Judiciary.uk 19 Feb 2017
Reference 2017-0021
Coroner: Andrew Tweddle
North East
County Durham and Darlington
AI-generated concerns summaryThe coroner identified issues with describing prisoner behaviour and selecting appropriate language, which impacted risk assessment. There were also concerns about the normalisation of unusual behaviour, leading it not to be considered indicative of increased risk.
Addressed to: G4S; National Offender Management Service; Tees, Esk and Wear Valley NHS Trust
1 response identified · 3 indexed addressees. Read concerns and response evidence →
Report dated 27 Jan 2017
Added from Judiciary.uk 19 Feb 2017
Reference 2017-0020
Coroner: Roger Hatch
South East
Kent (North-West)
AI-generated concerns summaryThe coroner noted concerns regarding medical staff not following the post-partum haemorrhage protocol, inadequate supervision of staff grade anaesthetists, and delays in requesting urgent specialist help. Issues with insufficient note-keeping at the hospital were also identified.
Addressed to: Maidstone and Tunbridge Wells NHS Trust
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 31 Jan 2017
Added from Judiciary.uk 19 Feb 2017
Reference 2017-0019
Coroner: Heidi Connor
East Midlands
Nottinghamshire
AI-generated concerns summaryConcerns are raised about EMAS's local protocol allowing staff to deem resuscitation 'futile' without clear guidance, a deviation from national standards. There is also insufficient staff awareness and training on this significant protocol change.
Addressed to: East Midlands Ambulance Service NHS Trust
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 30 Jan 2017
Added from Judiciary.uk 19 Feb 2017
Reference 2017-0018
Coroner: Janet Napier
North West
Cheshire
AI-generated concerns summaryThe coroner noted the absence of a cycle lane, an obstruction on the footpath from a road sign support, and an unexplained dip in the kerb edge, all of which may have contributed to a cyclist leaving the footpath.
Addressed to: Cheshire East Council, Highway Department
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 30 Jan 2017
Added from Judiciary.uk 19 Feb 2017
Reference 2017-0017
Coroner: Janet Napier
North West
Cheshire
AI-generated concerns summaryThe coroner raised concerns regarding agency staff's documentation practices and their awareness of monitoring clinical changes and urgently seeking medical or nursing help.
Addressed to: Halton Clinical Commissioning Group; St Helens Clinical Commissioning Group
1 response identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 27 Jan 2017
Added from Judiciary.uk 19 Feb 2017
Reference 2017-0016
Coroner: Andrew Bradley
South East
Hampshire (North East)
AI-generated concerns summaryThe coroner noted that the railway crossing is unmanned and unprotected, with the only direct warning being a horn sounded by the driver 400m from the crossing, and visibility obscured by a fence.
Addressed to: HM Principal Inspector of Railways; Office of Rail and Road
0 responses identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 26 Jan 2017
Added from Judiciary.uk 19 Feb 2017
Reference 2017-0015
Coroner: Thomas Osborne
East of England
Bedfordshire and Luton
AI-generated concerns summaryThe coroner raised concerns that mothers requesting Caesarean sections are not having their wishes respected, which can put babies' lives at risk. This was exemplified by Baby Albie's case where the mother's requests for a C-section were not granted.
Addressed to: Luton and Dunstable Hospital
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 31 Jan 2017
Added from Judiciary.uk 19 Feb 2017
Reference 2017-0013
Coroner: Philip Spinney
Wales
South Wales Central
AI-generated concerns summaryThe coroner identified a lack of local protocols and specific training for intercostal drain insertion, along with the unavailability of real-time ultrasound guidance supported by British Thoracic Society Guidelines.
Addressed to: Cardiff and Vale University Health Board
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 3 Feb 2017
Added from Judiciary.uk 19 Feb 2017
Reference 2017-0012
Coroner: Grahame Short
South East
Southampton and New Forest
AI-generated concerns summaryThe coroner raises concerns about the lack of confirmation that door limit switches have been installed on the MV Moonray's goods lift, and that Marine Safety Advisory No. 20-13 has been implemented for similar lifts on other ships.
Addressed to: Mirage Finance Incorporated; Primebulk Shipmanagement Limited
0 responses identified · 2 indexed addressees. Read concerns and response evidence →