Report dated 16 Apr 2025
Added from Judiciary.uk 27 Apr 2026
Reference 2026-0217
Coroner: Valerie Charbit
London
West London
AI-generated concerns summaryDifficulties in lay recognition of cardiac arrest, understanding of defibrillator use, and insufficient mandatory Sudden Cardiac Arrest training in football are identified. Concerns also include limited cardiac screening for young people and imperfect genetic cascade communication.
Addressed to: Association of Ambulance Chief Executives; Cardiac Risk in the Young (CRY); Department of Health and Social Care (DHSC); Faculty of Sport and Exercise Medicine UK; National Health Service England (NHSE); Resuscitation Council UK; South Central Ambulance Service; St John Ambulance; Sudden Cardiac Arrest UK (SCA UK); British Society for Genetic Medicine; Football Association; UK National Screening Committee; UK Sports Institute (formerly the English Institute of Sport)
13 responses identified · 13 indexed addressees. Read concerns and response evidence →
Report dated 14 Apr 2026
Added from Judiciary.uk 17 Apr 2026
Reference 2026-0216
Coroner: Louise Hunt
West Midlands
Birmingham and Solihull
AI-generated concerns summaryThe coroner noted that Wi-Fi issues hindered staff from accurately recording therapeutic observation comments, and there was no care plan in place to address physical health risks like sleep apnoea for patients on long-term mental health medication.
Addressed to: Birmingham and Solihull Mental Health NHS Foundation Trust
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 14 Apr 2026
Added from Judiciary.uk 17 Apr 2026
Reference 2026-0215
Coroner: Nicholas Graham
South East
Oxfordshire
AI-generated concerns summaryThe coroner noted concerns regarding hazards created by the prolonged storage of household items in living areas, especially for vulnerable tenants. There was a lack of clear policies governing storage duration during necessary works and mitigating steps for extended storage.
Addressed to: Sanctuary Housing Association
0 responses identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 14 Apr 2026
Added from Judiciary.uk 17 Apr 2026
Reference 2026-0214
Coroner: Andrew Bridgman
North West
Manchester South
AI-generated concerns summaryThe wheelchair seat cushion's velcro attachment failed, potentially due to repeated removal, and there was no assessment of the vehicle restraint system's fit to the individual wheelchair user and her chair.
Addressed to: British Health Trades Association; Wheelchair Alliance; Wheelchair Accessible Vehicle Converters Association
3 responses identified · 3 indexed addressees. Read concerns and response evidence →
Report dated 10 Apr 2026
Added from Judiciary.uk 17 Apr 2026
Reference 2026-0213
Coroner: Heath Westerman
West Midlands
Shropshire, Telford and Wrekin
AI-generated concerns summaryDifficulties locating the appropriate tab for cardiac arrest on the JRCALC app, paramedics' inability to follow guidelines due to competing tasks, and insufficient Naloxone vials on ambulances were identified.
Addressed to: Joint Royal Colleges Ambulance Liaison Committee; West Midlands Amublance Service
2 responses identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 10 Apr 2026
Added from Judiciary.uk 17 Apr 2026
Reference 2026-0212
Coroner: Darren Stewart
South East
Surrey
AI-generated concerns summaryThe coroner noted concerns regarding the £250 per week allowance for living expenses in Proceeds of Crime Act Restraint Orders, a figure unchanged since 2009, which makes it difficult for individuals and their dependents to meet reasonable costs. There are also concerns about the challenging process to vary this amount …
Addressed to: Attorney General of England and Wales and the Director of Public Prosecutions
0 responses identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 11 Mar 2026
Added from Judiciary.uk 17 Apr 2026
Reference 2026-0211
Coroner: Mary Hassell
London
Inner North London
AI-generated concerns summaryThe coroner highlighted concerns regarding the widespread availability of drugs within HMP Pentonville. Additionally, the prison drug service's interaction with the deceased was found to be insufficient, with the recovery worker not reviewing medical records or conducting a meaningful discussion about his drug use.
Addressed to: HM Prison Pentonville; HM Prison & Probation Service; Phoenix Futures; Practice Plus Group
4 responses identified · 4 indexed addressees. Read concerns and response evidence →
Report dated 8 Feb 2022
Added from Judiciary.uk 17 Apr 2026
Reference 2026-0210
Coroner: Sean Horstead
East of England
Essex
AI-generated concerns summaryThe coroner identified inadequate formal training for EPUT Care Coordinators, which led to issues like poor record keeping, failure to update care plans and risk assessments, and insufficient attention to patient disengagement from services.
Addressed to: Department of Health and Social Care; Essex Partnership NHS Trust; Health Education England; NHS England
3 responses identified · 4 indexed addressees. Read concerns and response evidence →
Report dated 1 Apr 2026
Added from Judiciary.uk 17 Apr 2026
Reference 2026-0193
Coroner: David Place
North East
Sunderland
AI-generated concerns summaryThe national NHS pathways telephone triage system provides no guidance to health advisers on maintaining telephone contact with patients expressing suicidal intent, specifically how to ameliorate the risk of them ending their own life.
Addressed to: NHS England
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 1 Apr 2026
Added from Judiciary.uk 17 Apr 2026
Reference 2026-0188
Coroner: Paul Marks
Hull and East Riding
AI-generated concerns summaryThe coroner noted the need for meticulous attention to detail in the insertion, maintenance, and documentation of intravenous access devices across the NHS, highlighting awareness of potential complications.
Addressed to: NHS England
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 25 Mar 2026
Added from Judiciary.uk 14 Apr 2026
Reference 2026-0178
Coroner: Fiona Wilcox
London
Inner West London
AI-generated concerns summaryConcerns include child death investigation teams missing forensic opportunities and potential poisoning, and nannies lacking training on chlorpheniramine administration. The report also notes the absence of national nanny regulation and potentially insufficient product warnings.
Addressed to: College of Policing; Haleon UK Trading Limited; Metropolis; National Crime Agency
4 responses identified · 4 indexed addressees. Read concerns and response evidence →
Report dated 6 Apr 2026
Added from Judiciary.uk 13 Apr 2026
Reference 2026-0207
Coroner: Nigel Parsley
East of England
Suffolk
AI-generated concerns summaryAn incorrectly implemented temporary traffic management plan, based on inaccurate initial coordinates, led to inadequate coning and insufficient signage. These issues, identified following a plan 'flip' on-site, increased the likelihood of a road traffic collision.
Addressed to: Anglican Water; Secretary of State for Transport; Suffolk County Council
5 responses identified · 3 indexed addressees. Read concerns and response evidence →
Report dated 12 Feb 2026
Added from Judiciary.uk 13 Apr 2026
Reference 2026-0203
Coroner: Crispin Butler
South East
Buckinghamshire
AI-generated concerns summaryThe initial incident investigation lacked robustness and was not updated with new evidence. Concerns were raised about persistent bed availability issues, the lack of face-to-face psychiatric review, and insufficient communication with families during waits for admission.
Addressed to: Oxford Health NHS Foundation Trust
0 responses identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 2 Apr 2026
Added from Judiciary.uk 13 Apr 2026
Reference 2026-0195
Coroner: Darren Stewart
East of England
Suffolk
AI-generated concerns summaryThe coroner noted incorrect discharge advice given to a patient about weight-bearing and mobility, potentially increasing DVT risk, along with inadequate record-keeping regarding medical rationale for such advice.
Addressed to: West Suffolk NHS Foundation Trust
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 8 Apr 2026
Added from Judiciary.uk 13 Apr 2026
Reference 2026-0204
Coroner: Darren Stewart
South East
Surrey
AI-generated concerns summaryThe coroner identified a lack of mandatory policy for private patients with high-risk Squamous Cell Carcinoma to be referred to a specialist skin MDT, unlike those treated in the NHS. This creates a risk of receiving inferior care compared to NHS patients.
Addressed to: Care Quality Commission; Royal College of Surgeons
2 responses identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 2 Feb 2026
Added from Judiciary.uk 13 Apr 2026
Reference 2026-0202
Coroner: Sean Horstead
East of England
Essex
AI-generated concerns summaryInsufficient communication with the patient and family regarding critical end-of-life care decisions. Staff were also insufficiently familiar with Trust policies on transitioning to end-of-life care.
Addressed to: East Suffolk and North Essex NHS Foundation Trust
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 31 Mar 2026
Added from Judiciary.uk 13 Apr 2026
Reference 2026-0189
Coroner: Hassan Shah
East Midlands
Northamptonshire
AI-generated concerns summaryThe care plan's risk assessment lacked medical input and was insufficient for persons on blood thinners, alongside an unclear process for escalating to medical personnel following a fall.
Addressed to: CQC; QCC; Care Bureau; West Northamptonshire Council
3 responses identified · 4 indexed addressees. Read concerns and response evidence →
Report dated 30 Mar 2026
Added from Judiciary.uk 13 Apr 2026
Reference 2026-0199
Coroner: Robert Simpson
South East
Berkshire
AI-generated concerns summaryThe coroner noted inaccurate falls risk assessments due to incorrect data, leading to incorrect low-risk gradings, and a lack of auditing for their accuracy. Concerns were also raised that the urgency of anticoagulation reversal is poorly understood, and the post-falls proforma lacks relevant prompts.
Addressed to: Frimley Health NHS Foundation Trust
0 responses identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 8 Apr 2026
Added from Judiciary.uk 13 Apr 2026
Reference 2026-0200
Coroner: Alexandra Pountney
East Midlands
Nottingham and Nottinghamshire
AI-generated concerns summaryThe report describes a lack of formal information sharing between community forensic teams, prison healthcare, and operational prison staff, hindering risk assessment and management. Alert categorisation on NOMIS/DPS was also found to be too broad.
Addressed to: HMP Nottingham; Ministry of Justice; Northampton Healthcare NHS Foundation Trust; Nottingham Healthcare NHS Foundation Trust; Nottinghamshire Healthcare NHS Foundation Trust
3 responses identified · 5 indexed addressees. Read concerns and response evidence →
Report dated 7 Apr 2026
Added from Judiciary.uk 13 Apr 2026
Reference 2026-0206
Coroner: Helen Rimmer
North West
Liverpool & Wirral
AI-generated concerns summaryThe coroner highlights an unresolved conflict between Building Regulations 2010 and BSI Standards concerning the measurement of barrier height, particularly when a wall or parapet serves as guarding. Clarity is also needed on horizontal railing risks for older children and adults.
Addressed to: Secretary of State for building safety, fire and construction
1 response identified · 1 indexed addressee. Read concerns and response evidence →