Report dated 20 Dec 2024
Added from Judiciary.uk 27 Dec 2024
Reference 2024-0702
Coroner: Amanda Bewley
East Midlands
Nottingham and Nottinghamshire
AI-generated concerns summaryThe coroner identified that search engines readily return websites selling addictive prescription medications, with insufficient monitoring of online supply chains. Concerns were also raised about banks' involvement in criminal enterprises and the ineffective detection of these operations.
Addressed to: Department for Science, Innovation and Technology; Department of Health and Social Care; Minister of State for Prisons, Parole and Probation; Financial Conduct Authority; Medical and Healthcare Regulatory Authority
3 responses identified · 5 indexed addressees. Read concerns and response evidence →
Report dated 20 Dec 2024
Added from Judiciary.uk 27 Dec 2024
Reference 2024-0702-wp94639
Coroner: Caroline Topping
South East
Surrey
AI-generated concerns summaryThe coroner identified gaps at HMP Coldingley in recording and sharing prisoner welfare information, mental health training for staff, and out-of-hours clinical mental health provision. The report also noted no process to expedite parole hearings for IPP prisoners with withdrawn recall allegations.
Addressed to: HMP Coldingley; HMPPS; Ministry of Justice; NHS England
3 responses identified · 4 indexed addressees. Read concerns and response evidence →
Report dated 28 Oct 2024
Added from Judiciary.uk 27 Dec 2024
Reference 2024-0701
Coroner: John Gittins
Wales
North Wales (East and Central)
AI-generated concerns summaryThe coroner noted that a clinician prescribed a sedative without reviewing the patient's full medical records, which meant they were unaware of her enhanced falls risk and other behavioural issues.
Addressed to: Betsi Cadwaladr University Health Board
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 20 Dec 2024
Added from Judiciary.uk 27 Dec 2024
Reference 2024-0700
Coroner: Adrian Farrow
North West
Manchester South
AI-generated concerns summaryThe coroner identified a lack of inter-specialty communication between different teams involved in patient care, particularly for complex cases and between different NHS Trusts. There is no formal framework to facilitate this communication, leading to insufficient understanding of care plans.
Addressed to: Department of Health and Social Care
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 20 Dec 2024
Added from Judiciary.uk 27 Dec 2024
Reference 2024-0699
Coroner: Samantha Goward
East of England
Norfolk
AI-generated concerns summaryThe coroner noted significantly lengthy waiting lists for adult ADHD services, meaning patients at risk do not receive treatment or monitoring, potentially leading to deterioration or harmful behaviour. A shortage of medication for diagnosed patients was also identified.
Addressed to: NHS England
2 responses identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 20 Dec 2024
Added from Judiciary.uk 27 Dec 2024
Reference 2024-0698
Coroner: Rachael Griffin
South West
Dorset
AI-generated concerns summaryThe coroner raises concerns that pleasure vessels lack similar safety mitigations to commercial vessels, including no requirement for safety briefings or prohibitions against helming under the influence of alcohol or drugs. There is also no legal requirement for all vessels to carry or wear personal flotation devices.
Addressed to: Department for Transport; Offshore Racing Council; Royal Yachting Association
2 responses identified · 3 indexed addressees. Read concerns and response evidence →
Report dated 19 Dec 2024
Added from Judiciary.uk 27 Dec 2024
Reference 2024-0697
Coroner: Heidi Connor
South East
Berkshire
AI-generated concerns summaryThe coroner highlights significant ambulance response delays, noting South Central Ambulance Service's sustained operation at high-pressure levels and extensive hours lost to hospital queues. Concerns are also raised about a lack of national oversight regarding PFD reports to ambulance trusts.
Addressed to: Department of Health and Social Care; NHS England
2 responses identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 16 Dec 2024
Added from Judiciary.uk 27 Dec 2024
Reference 2024-0696
Coroner: Duncan Ritchie
West Midlands
Staffordshire and Stoke-on-Trent
AI-generated concerns summaryThe coroner noted concerns about the fragmentation of medical notes across different hospital teams, which led to a multi-disciplinary team decision being overlooked. The trust's interim solutions rely on manual transcription, and a unified electronic patient records system is not yet in place.
Addressed to: University Hospitals of North Midlands NHS Trust
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 18 Dec 2024
Added from Judiciary.uk 27 Dec 2024
Reference 2024-0695
Coroner: Helen Rimmer
North West
Liverpool and Wirral
AI-generated concerns summaryThe standard operating procedure for radiographers did not include provisions for them to escalate care or initiate an urgent arrest call when signs of imminent danger to life were present. It was unknown if this issue extended to other trusts nationally.
Addressed to: NHS England
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 10 Dec 2024
Added from Judiciary.uk 27 Dec 2024
Reference 2024-0694
Coroner: Timothy Brennand
North West
Manchester West
AI-generated concerns summaryThe coroner identified inconsistent terminology in care plans regarding supervision levels and insufficient staff training on these requirements. Concerns were also raised about staff's professional curiosity and their confidence in emergency first aid for choking.
Addressed to: Bolton Cares
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 22 Oct 2024
Added from Judiciary.uk 24 Dec 2024
Reference 2024-0693
Coroner: Simon Milburn
East of England
Cambridgeshire & Peterborough
AI-generated concerns summaryThe coroner noted the absence of a system to ensure routine CT scan reports are reviewed by clinicians, despite a similar incident previously, with no immediate solution in place.
Addressed to: NORTH WEST ANGLIA NHS FOUNDATION TRUST
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 17 Dec 2024
Added from Judiciary.uk 19 Dec 2024
Reference 2024-0692
Coroner: Sonia Hayes
East of England
Essex
AI-generated concerns summaryThe coroner raised concerns regarding medication administration despite recorded allergies, the lack of comprehensive discharge information for a vulnerable patient sent to a care home, and insufficient staffing on Notley Ward.
Addressed to: Mid & South Essex NHS Trust
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 13 Dec 2024
Added from Judiciary.uk 19 Dec 2024
Reference 2024-0691
Coroner: Nigel Parsley
East of England
Suffolk
AI-generated concerns summaryThe coroner raises concerns about the persistent lack of mental health inpatient beds, leading to admission delays. Additionally, the report notes that the views of the patient, their family, and an experienced mental health professional were deemed insufficient for voluntary admission.
Addressed to: Department of Health and Social Care
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 16 Dec 2024
Added from Judiciary.uk 19 Dec 2024
Reference 2024-0690
Coroner: Penelope Schofield
South East
West Sussex, Brighton and Hove
AI-generated concerns summaryThe coroner raises concerns about the lack of inpatient mental health beds, leading to long waits in unsuitable A&E environments, particularly for autistic and transgender patients. There are also gaps in services for high-risk individuals not meeting detention criteria and significant delays in referrals for treatment.
Addressed to: Department of Health and Social Care; NHS England
2 responses identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 16 Dec 2024
Added from Judiciary.uk 19 Dec 2024
Reference 2024-0689
Coroner: Penelope Schofield
South East
West Sussex, Brighton and Hove
AI-generated concerns summaryThe report highlights a significant lack of inpatient mental health beds, resulting in prolonged A&E waits and an unsuitable environment for patients, particularly those who are autistic or neurodiverse. There are also identified gaps in services and funding for psychosocial support.
Addressed to: Sussex ICB
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 13 Dec 2024
Added from Judiciary.uk 18 Dec 2024
Reference 2024-0688
Coroner: Sonia Hayes
East of England
Essex
AI-generated concerns summaryThe coroner noted significant omissions in medical record-keeping and a failure to escalate Laura-Jane as a deteriorating patient in accordance with national guidance. Concerns were also raised about the miscategorisation of her collapse and the inadequate recognition of hypovolemia despite her expressed concerns.
Addressed to: Mid & South Essex NHS Trust; Royal College of Obstetricians and Gynaecology for Clinical Quality
2 responses identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 13 Dec 2024
Added from Judiciary.uk 18 Dec 2024
Reference 2024-0687
Coroner: Sally Olsen
South East
Hampshire, Portsmouth and Southampton
AI-generated concerns summaryThe post-operative care pathway for gastric bypass patients was not followed, as Ms Evans did not receive daily specialist review and her significant abdominal pain was not escalated to a senior doctor.
Addressed to: Portsmouth Hospital NHS Trust
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 24 Oct 2024
Added from Judiciary.uk 18 Dec 2024
Reference 2024-0686
Coroner: Roger Hatch
South East
North West Kent
AI-generated concerns summaryThe coroner identified concerns regarding unsafe paramedic driving standards and the insufficient handling of related complaints. Additionally, there was no formal complaint procedure in place, and questions were raised about the independence and regularity of driving assessments.
Addressed to: South East Coast Ambulance Service
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 12 Dec 2024
Added from Judiciary.uk 18 Dec 2024
Reference 2024-0685
Coroner: Sonia Hayes
East of England
Essex
AI-generated concerns summaryThe coroner noted the acute Trust's protocol was not followed as no Datix report was raised for a split Hickman Catheter despite infection risk. The catheter also remained in situ for an extended period, even with signs of infection.
Addressed to: Mid & South Essex NHS Trust
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 11 Dec 2024
Added from Judiciary.uk 18 Dec 2024
Reference 2024-0684
Coroner: Mary Hassell
London
Inner North London
AI-generated concerns summaryThe night concierge at the hostel lacked first aid and naloxone training and was unaware if a defibrillator was available. The coroner also noted that no staff attempted cardiopulmonary resuscitation during the incident.
Addressed to: St Mungo’s
1 response identified · 1 indexed addressee. Read concerns and response evidence →