PFD · Response tracker

PFD Response Tracker

32 total 16 with responses identified 9 with 0 responses identified (past 2 years) 0 response window open 7 historic with 0 responses identified

Live tracking of every Prevention of Future Deaths report and the published responses identified for them under Regulation 28's 56-day deadline.

How response counts are interpreted — 56-day deadline, Judiciary.UK data

Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date. We rely on Judiciary.UK for response data, so this tracker shows published responses we have identified there.

A report with at least one published response is counted as having a response identified, even if not every listed addressee has a separate published response. Reports with 0 responses identified are split by whether the response window is still open, within the last two years after that window, or older than two years. This is because addressee data from Judiciary.UK can be unreliable: address fragments, job titles, and redacted names are sometimes parsed as separate addressees, and a single response PDF may cover multiple parties.

Historic reports with 0 responses identified are more than two years old. Older reports may have received a response that was never made public. Treat these counts as a neutral data-coverage signal, not confirmed non-compliance.

32 reports have a non-response confirmed by the Chief Coroner.

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32 reports

Date ↓	Deceased	Addressee(s)	Responses identified
19 Sep 2025	Kwabena Amoateng AI-generated concerns summaryA critical Paediatric Respiratory Action Plan was mislabelled and misfiled in online records, making healthcare professionals unaware of its existence. This reflects a lack of coordinated process for producing and …	South-East London Integrated Care System Chief Nursing Officer, NHS North-East London Integrated Care Board South East London ICB National Medical Director, NHS England	0 responses · 4 indexed addressees CC
19 Sep 2025	Luke Chatterton AI-generated concerns summaryThe coroner noted delays in advanced life support (ALS) resuscitation in a mental health hospital, including issues with IV line insertion and adrenaline administration. Concerns also related to the lack …	Croydon University Hospital Medicines and Healthcare Products Regulatory Agency Royal College of Emergency Medicine Royal College of Psychiatrists Secretary of State for Health & Social Care [REDACTED] South London & Maudsley NHS Foundation Trust	0 responses · 6 indexed addressees CC
16 Sep 2025	John Franklin AI-generated concerns summaryThe coroner raised concerns that Mr Franklin was discharged home before a careline/lifeline pendant was provided, and there was conflicting information about whether it had been installed when he was …	Worcestershire County Council	0 responses · 1 indexed addressees CC
5 Sep 2025	Victoria Taylor AI-generated concerns summarySecondary mental health services did not offer support or a treatment pathway for Ms Taylor's unresolved childhood trauma, and safety plans were limited. The assessment documents lacked discussion of NHS …	Tees, Esk and Wear Valleys NHS Foundation Trust	0 responses · 1 indexed addressees CC
1 Aug 2025	Benjamin Buckfield AI-generated concerns summaryThe coroner noted concerns regarding the unchecked, open trade of illegal drugs at the festival and a policy allowing entry for individuals caught with drugs unless they are considered dealers, …	Boomtown Festival Hampshire and IOW Constabulary	0 responses · 2 indexed addressees CC
3 Jun 2025	Anthony Wood AI-generated concerns summaryThe coroner noted insufficient staffing when attending a high-risk, severely frail patient, leading to a fall from bed. There were no crash mats at the bedside, despite the patient's known …	Epsom and St. Helier University Hospitals NHS Trust	0 responses · 1 indexed addressees CC
23 May 2025	William Armstrong AI-generated concerns summaryThe coroner identified a lack of specific guidance for online sellers of a reportable poison, leading to insufficient evaluation of small purchases for potential self-harm. Concerns were also raised about …	Home Office	0 responses · 1 indexed addressees CC
23 May 2025	Kelly Walsh AI-generated concerns summaryThe coroner noted gaps in guidance for sellers of a reportable poison regarding purchases for self-harm, as current advice focuses on malicious misuse. Vendors were unaware of this potential and …	Home Office	0 responses · 1 indexed addressees CC
6 Mar 2025	John McLoughlin AI-generated concerns summaryThe coroner identified that the Peer Support system for pilots is insufficient for those with severe mental health difficulties, noting a lack of adequate support within the aviation industry for …	British Airline Pilots’ Association Civil Aviation Authority	1 responses · 2 indexed addressees CC
21 Feb 2025	Luke Worrell AI-generated concerns summaryClinical staff lacked awareness of clozapine's potential fatal side effects, and a Community Treatment Order was used inappropriately despite evidence supporting a Mental Health Act section.	Care Quality Commission Department of Health and Social Care Medicines and Healthcare Products Regulatory Agency NHS England Royal College of Psychiatrists	4 responses · 5 indexed addressees CC
10 Dec 2024	Peter McCarthy AI-generated concerns summaryThe coroner is concerned that Care4U Healthcare lacks a protocol to prevent clients who have fallen from being given anticoagulant medication without medical oversight, as staff cannot identify contraindications with …	Care4U Healthcare	0 responses · 1 indexed addressees CC
25 Nov 2024	Margaret Feeney AI-generated concerns summaryThe coroner noted a lack of measures at Macklin Street Surgery and Daynight pharmacy to prevent excess medication prescriptions for at-risk patients during longer bank holiday periods, increasing overdose risk.	Daynight Pharmacy Department of Health and Social Care Macklin Street Surgery NHS Derby and Derbyshire Integrated Care Board	3 responses · 4 indexed addressees CC
14 Oct 2024	Stephen Sleaford AI-generated concerns summaryThe coroner raises concerns about a lack of first aid and CPR training for prison officers, including its omission from new officer foundation training programmes. Additionally, officers routinely permit cell …	HM Prison and Probation Service Ministry of Justice	1 responses · 1 indexed addressees CC
19 Sep 2024	Gordon Long AI-generated concerns summaryThe coroner noted the Trust's inability to explain a delayed vascular referral and the inadequate standard of its patient safety incident investigation. There was also no clear evidence that the …	Barking, Havering & Redbridge University Trust	0 responses · 1 indexed addressees CC
27 Aug 2024	Dave Onawelo AI-generated concerns summaryThe coroner identified inadequate monitoring and delayed medical intervention for a critically ill patient with sickle cell anaemia, which might have prevented a fatal outcome. Concerns also involved emergency department …	Barts Health NHS Foundation Trust Department of Health and Social Care	1 responses · 2 indexed addressees CC
13 Aug 2024	Margaret Huntley AI-generated concerns summaryThe coroner identified a lack of understanding and guidance for ambulance service staff regarding the importance of steroid medication and managing potential steroid insufficiency. Concerns were also raised about the …	Association of Ambulance Chief Executives NHS England North East Ambulance Service NHS Foundation Trust Royal College of General Practitioners	3 responses · 4 indexed addressees CC
8 Aug 2024	Sean Davies AI-generated concerns summaryThe coroner raised concerns about the incomplete implementation of risk formulations for prisoners with IPP sentences. Welfare checks by prison officers did not adhere to national guidance, and some operational …	HMP Swaleside Ministry of Justice	0 responses · 2 indexed addressees CC
5 Aug 2024	Janet Harrison AI-generated concerns summaryThe coroner noted that other properties in the local area have walls built with unsafe dimensions, similar to one that collapsed during Storm Eunice, which creates a risk of further …	Eastleigh Borough Council Southampton City Council	1 responses · 2 indexed addressees CC
1 Aug 2024	Matthew Braben AI-generated concerns summaryThe coroner identified gaps in prison policy for recognising childbirth as a mental health risk factor and issues with ACCT process robustness and staff training. Concerns also included the negative …	His Majesty’s Prison and Probation Service Ministry of Justice	0 responses · 2 indexed addressees CC
25 Jul 2024	Elizabeth Holder AI-generated concerns summaryThe Trust failed to prevent a predictable and avoidable fall that resulted in death. The Trust's governance systems did not identify or reflect upon care failings during the subsequent After …	Barts Health Foundation Trust Department of Health and Social Care	1 responses · 2 indexed addressees CC
12 Jul 2024	Jason Holland AI-generated concerns summaryConcerns were raised that standard competence-based training for Mobile Elevated Working Platforms (MEWPs) operators, including IPAF certification, lacks practical 'at height' or 'basket to basket' rescue drills, which are crucial …	Independent Training Standards Scheme and Register LANTRA National Open College Network as part of the Construction Plant Competence Construction Scheme National Plant Operators Scheme International Powered Access Federation Road Transport Industry Training Board	7 responses · 6 indexed addressees CC
27 Jun 2024	Emily Collishaw AI-generated concerns summaryThe coroner noted insufficient support for the individual's health and abstinence, with concerns that referral for residential care should have been earlier. Additionally, there were long and increasing waiting times …	Department of Health and Social Care Ministry of Housing, Communities & Local Governments NHS England SE London Integrated Care Board	3 responses · 4 indexed addressees CC
11 Jun 2024	Yuri Hatton AI-generated concerns summaryConcerns included insufficient official training for most Operational Support Grades (OSGs) who are first responders, and inadequate monitoring of first aid training records. The coroner also noted that first aid …	HMPPS HMP Wandsworth	0 responses · 2 indexed addressees CC
11 Jun 2024	Daniel Beckford AI-generated concerns summaryThe first aid training for prison officers lacked clarity on the use of rescue breaths during resuscitation attempts, not aligning with current Resuscitation Council UK advice.	HMPPS HMP Wandsworth	0 responses · 2 indexed addressees CC
29 May 2024	Hayley Cowan AI-generated concerns summaryThe coroner raises concerns about the lack of consistent and clear guidance for Mental Health trusts regarding the definition and conduct of Section 17 leave, particularly concerning patient supervision definitions …	Department of Health and Social Care Ministry of Justice	1 responses · 2 indexed addressees CC
29 May 2024	Christopher MacGillivray AI-generated concerns summaryThe Prison Service Instruction (PSI) 64/2011 does not provide mandatory procedures for communicating known self-harm risks during the unplanned release of remand prisoners. This absence of guidance raises concerns about …	Ministry of Justice	0 responses · 1 indexed addressees CC
21 May 2024	Christine McDonald AI-generated concerns summaryThe report identifies concerns regarding the non-use of emergency response codes, which left first responders unprepared for the situation they attended. It also notes the difficulty in training staff for …	HMP Styal Ministry of Justice	1 responses · 2 indexed addressees CC
14 Apr 2024	Darren Docherty AI-generated concerns summaryThe coroner raised concerns that individuals released from prison often lack accommodation, which prevents them from accessing necessary GP and community mental health services.	HMP Stoke Health Local Authority for Stoke on Trent	1 responses · 2 indexed addressees CC
26 Mar 2024	Mark Kinzley AI-generated concerns summaryConcerns included the appropriateness of Mr Kinzley's care location and the absence of a formal capacity assessment. Furthermore, no mental health assessment was initiated despite his history of mental illness, …	London Borough of Redbridge Cambridge Nursing Home Ltd Evergreen Surgery Integrated Care Board (ICB) for North-East London	2 responses · 4 indexed addressees CC
13 Feb 2024	Joshua Burgess AI-generated concerns summaryLack of clear instructions from the neurology department to GPs regarding medication changes, combined with a GP surgery workflow that prevented clinicians from reviewing crucial correspondence. This resulted in difficulties …	Brook Medical Centre Godfrey Care University Hospitals of North Midlands NHS Trust	2 responses · 3 indexed addressees CC
6 Feb 2024	Mark Pryor AI-generated concerns summaryThe coroner raised concerns that Health Care Professionals (HCPs) in police custody suites may not be receiving sufficient and adequate training to practice effectively or safely.	Department of Health and Social Care HCRG Care Services Ltd Ministry of Justice	2 responses · 3 indexed addressees CC
19 Jan 2024	Matthew Wickes AI-generated concerns summaryThe coroner raised concerns about academic staff awareness and understanding of student mental health, noting non-compulsory training and insufficient guidance on identifying struggles, especially for neurodiverse students. A gap between …	University of Southampton	0 responses · 1 indexed addressees CC

Kwabena Amoateng

Report dated 19 Sep 2025 Reference 2025-0429

AI-generated concerns summaryA critical Paediatric Respiratory Action Plan was mislabelled and misfiled in online records, making healthcare professionals unaware of its existence. This reflects a lack of coordinated process for producing and storing such important documents consistently in clinical records.

Addressed to: South-East London Integrated Care System; Chief Nursing Officer, NHS North-East London Integrated Care Board; South East London ICB; National Medical Director, NHS England

0 responses identified · 4 indexed addressees · Chief Coroner confirmed non-response

Luke Chatterton

Report dated 19 Sep 2025 Reference 2025-0470

AI-generated concerns summaryThe coroner noted delays in advanced life support (ALS) resuscitation in a mental health hospital, including issues with IV line insertion and adrenaline administration. Concerns also related to the lack of specific guidelines for managing suspected acute obstruction in patients taking Clozapine and identifying antipsychotic risks.

Addressed to: Croydon University Hospital; Medicines and Healthcare Products Regulatory Agency; Royal College of Emergency Medicine; Royal College of Psychiatrists; Secretary of State for Health & Social Care [REDACTED]; South London & Maudsley NHS Foundation Trust

0 responses identified · 6 indexed addressees · Chief Coroner confirmed non-response

John Franklin

Report dated 16 Sep 2025 Reference 2025-0474

AI-generated concerns summaryThe coroner raised concerns that Mr Franklin was discharged home before a careline/lifeline pendant was provided, and there was conflicting information about whether it had been installed when he was found on the floor.

Addressed to: Worcestershire County Council

0 responses identified · 1 indexed addressee · Chief Coroner confirmed non-response

Victoria Taylor

Report dated 5 Sep 2025 Reference 2025-0455

AI-generated concerns summarySecondary mental health services did not offer support or a treatment pathway for Ms Taylor's unresolved childhood trauma, and safety plans were limited. The assessment documents lacked discussion of NHS trauma treatment pathways, and no multi-agency meeting was called despite multiple agencies being involved.

Addressed to: Tees, Esk and Wear Valleys NHS Foundation Trust

0 responses identified · 1 indexed addressee · Chief Coroner confirmed non-response

Benjamin Buckfield

Report dated 1 Aug 2025 Reference 2025-0395

AI-generated concerns summaryThe coroner noted concerns regarding the unchecked, open trade of illegal drugs at the festival and a policy allowing entry for individuals caught with drugs unless they are considered dealers, which creates a demand for replacement drugs.

Addressed to: Boomtown Festival; Hampshire and IOW Constabulary

0 responses identified · 2 indexed addressees · Chief Coroner confirmed non-response

Anthony Wood

Report dated 3 Jun 2025 Reference 2025-0282

AI-generated concerns summaryThe coroner noted insufficient staffing when attending a high-risk, severely frail patient, leading to a fall from bed. There were no crash mats at the bedside, despite the patient's known propensity to push staff.

Addressed to: Epsom and St. Helier University Hospitals NHS Trust

0 responses identified · 1 indexed addressee · Chief Coroner confirmed non-response

William Armstrong

Report dated 23 May 2025 Reference 2025-0257

AI-generated concerns summaryThe coroner identified a lack of specific guidance for online sellers of a reportable poison, leading to insufficient evaluation of small purchases for potential self-harm. Concerns were also raised about vendors' unawareness of their products' misuse and the public's access to websites promoting methods to end life.

Addressed to: Home Office

0 responses identified · 1 indexed addressee · Chief Coroner confirmed non-response

Kelly Walsh

Report dated 23 May 2025 Reference 2025-0256

AI-generated concerns summaryThe coroner noted gaps in guidance for sellers of a reportable poison regarding purchases for self-harm, as current advice focuses on malicious misuse. Vendors were unaware of this potential and that their websites were used to promote suicide methods.

Addressed to: Home Office

0 responses identified · 1 indexed addressee · Chief Coroner confirmed non-response

John McLoughlin

Report dated 6 Mar 2025 Reference 2025-0131

AI-generated concerns summaryThe coroner identified that the Peer Support system for pilots is insufficient for those with severe mental health difficulties, noting a lack of adequate support within the aviation industry for escalating mental health problems.

Addressed to: British Airline Pilots’ Association; Civil Aviation Authority

1 response identified · 2 indexed addressees · Chief Coroner confirmed non-response

Luke Worrell

Report dated 21 Feb 2025 Reference 2025-0123

AI-generated concerns summaryClinical staff lacked awareness of clozapine's potential fatal side effects, and a Community Treatment Order was used inappropriately despite evidence supporting a Mental Health Act section.

Addressed to: Care Quality Commission; Department of Health and Social Care; Medicines and Healthcare Products Regulatory Agency; NHS England; Royal College of Psychiatrists

4 responses identified · 5 indexed addressees · Chief Coroner confirmed non-response

Peter McCarthy

Report dated 10 Dec 2024 Reference 2024-0679

AI-generated concerns summaryThe coroner is concerned that Care4U Healthcare lacks a protocol to prevent clients who have fallen from being given anticoagulant medication without medical oversight, as staff cannot identify contraindications with blister-packed medications.

Addressed to: Care4U Healthcare

0 responses identified · 1 indexed addressee · Chief Coroner confirmed non-response

Margaret Feeney

Report dated 25 Nov 2024 Reference 2024-0644

AI-generated concerns summaryThe coroner noted a lack of measures at Macklin Street Surgery and Daynight pharmacy to prevent excess medication prescriptions for at-risk patients during longer bank holiday periods, increasing overdose risk.

Addressed to: Daynight Pharmacy; Department of Health and Social Care; Macklin Street Surgery; NHS Derby and Derbyshire Integrated Care Board

3 responses identified · 4 indexed addressees · Chief Coroner confirmed non-response

Stephen Sleaford

Report dated 14 Oct 2024 Reference 2024-0550

AI-generated concerns summaryThe coroner raises concerns about a lack of first aid and CPR training for prison officers, including its omission from new officer foundation training programmes. Additionally, officers routinely permit cell observation panels to be obscured, and there is insufficient guidance on entering cells during emergencies.

Addressed to: HM Prison and Probation Service; Ministry of Justice

1 response identified · 1 indexed addressee · Chief Coroner confirmed non-response

Gordon Long

Report dated 19 Sep 2024 Reference 2024-0503

AI-generated concerns summaryThe coroner noted the Trust's inability to explain a delayed vascular referral and the inadequate standard of its patient safety incident investigation. There was also no clear evidence that the agreed action plan had led to improvements in care.

Addressed to: Barking, Havering & Redbridge University Trust

0 responses identified · 1 indexed addressee · Chief Coroner confirmed non-response

Dave Onawelo

Report dated 27 Aug 2024 Reference 2024-0470

AI-generated concerns summaryThe coroner identified inadequate monitoring and delayed medical intervention for a critically ill patient with sickle cell anaemia, which might have prevented a fatal outcome. Concerns also involved emergency department congestion, over-reliance on the NEWS algorithm, and insufficient clinical curiosity.

Addressed to: Barts Health NHS Foundation Trust; Department of Health and Social Care

1 response identified · 2 indexed addressees · Chief Coroner confirmed non-response

Margaret Huntley

Report dated 13 Aug 2024 Reference 2024-0452

AI-generated concerns summaryThe coroner identified a lack of understanding and guidance for ambulance service staff regarding the importance of steroid medication and managing potential steroid insufficiency. Concerns were also raised about the awareness and use of Steroid Emergency Cards, and GPs not routinely using the option to place alerts on ambulance systems for specific patient conditions.

Addressed to: Association of Ambulance Chief Executives; NHS England; North East Ambulance Service NHS Foundation Trust; Royal College of General Practitioners

3 responses identified · 4 indexed addressees · Chief Coroner confirmed non-response

Sean Davies

Report dated 8 Aug 2024 Reference 2024-0460

AI-generated concerns summaryThe coroner raised concerns about the incomplete implementation of risk formulations for prisoners with IPP sentences. Welfare checks by prison officers did not adhere to national guidance, and some operational support group officers lacked or did not follow essential training.

Addressed to: HMP Swaleside; Ministry of Justice

0 responses identified · 2 indexed addressees · Chief Coroner confirmed non-response

Janet Harrison

Report dated 5 Aug 2024 Reference 2024-0562

AI-generated concerns summaryThe coroner noted that other properties in the local area have walls built with unsafe dimensions, similar to one that collapsed during Storm Eunice, which creates a risk of further collapses and future deaths in strong storms.

Addressed to: Eastleigh Borough Council; Southampton City Council

1 response identified · 2 indexed addressees · Chief Coroner confirmed non-response

Matthew Braben

Report dated 1 Aug 2024 Reference 2024-0423

AI-generated concerns summaryThe coroner identified gaps in prison policy for recognising childbirth as a mental health risk factor and issues with ACCT process robustness and staff training. Concerns also included the negative mental health impact of extended cell confinement for prisoners, exacerbated by a shortage of gym instructors.

Addressed to: His Majesty’s Prison and Probation Service; Ministry of Justice

0 responses identified · 2 indexed addressees · Chief Coroner confirmed non-response

Elizabeth Holder

Report dated 25 Jul 2024 Reference 2024-0403

AI-generated concerns summaryThe Trust failed to prevent a predictable and avoidable fall that resulted in death. The Trust's governance systems did not identify or reflect upon care failings during the subsequent After Action Review, preventing remediation of contributing factors.

Addressed to: Barts Health Foundation Trust; Department of Health and Social Care

1 response identified · 2 indexed addressees · Chief Coroner confirmed non-response

Jason Holland

Report dated 12 Jul 2024 Reference 2024-0490

AI-generated concerns summaryConcerns were raised that standard competence-based training for Mobile Elevated Working Platforms (MEWPs) operators, including IPAF certification, lacks practical 'at height' or 'basket to basket' rescue drills, which are crucial for rapid response.

Addressed to: Independent Training Standards Scheme and Register; LANTRA; National Open College Network as part of the Construction Plant Competence Construction Scheme; National Plant Operators Scheme; International Powered Access Federation; Road Transport Industry Training Board

7 responses identified · 6 indexed addressees · Chief Coroner confirmed non-response

Emily Collishaw

Report dated 27 Jun 2024 Reference 2024-0431

AI-generated concerns summaryThe coroner noted insufficient support for the individual's health and abstinence, with concerns that referral for residential care should have been earlier. Additionally, there were long and increasing waiting times for residential rehabilitation placements.

Addressed to: Department of Health and Social Care; Ministry of Housing, Communities & Local Governments; NHS England; SE London Integrated Care Board

3 responses identified · 4 indexed addressees · Chief Coroner confirmed non-response

Yuri Hatton

Report dated 11 Jun 2024 Reference 2024-0608

AI-generated concerns summaryConcerns included insufficient official training for most Operational Support Grades (OSGs) who are first responders, and inadequate monitoring of first aid training records. The coroner also noted that first aid training on recognising unconsciousness was not prison-specific and new induction instructions had not yet been implemented.

Addressed to: HMPPS; HMP Wandsworth

0 responses identified · 2 indexed addressees · Chief Coroner confirmed non-response

Daniel Beckford

Report dated 11 Jun 2024 Reference 2024-0607

AI-generated concerns summaryThe first aid training for prison officers lacked clarity on the use of rescue breaths during resuscitation attempts, not aligning with current Resuscitation Council UK advice.

Addressed to: HMPPS; HMP Wandsworth

0 responses identified · 2 indexed addressees · Chief Coroner confirmed non-response

Hayley Cowan

Report dated 29 May 2024 Reference 2024-0291

AI-generated concerns summaryThe coroner raises concerns about the lack of consistent and clear guidance for Mental Health trusts regarding the definition and conduct of Section 17 leave, particularly concerning patient supervision definitions and practical instructions for staff.

Addressed to: Department of Health and Social Care; Ministry of Justice

1 response identified · 2 indexed addressees · Chief Coroner confirmed non-response

Christopher MacGillivray

Report dated 29 May 2024 Reference 2024-0297

AI-generated concerns summaryThe Prison Service Instruction (PSI) 64/2011 does not provide mandatory procedures for communicating known self-harm risks during the unplanned release of remand prisoners. This absence of guidance raises concerns about future deaths of at-risk prisoners.

Addressed to: Ministry of Justice

0 responses identified · 1 indexed addressee · Chief Coroner confirmed non-response

Christine McDonald

Report dated 21 May 2024 Reference 2024-0278

AI-generated concerns summaryThe report identifies concerns regarding the non-use of emergency response codes, which left first responders unprepared for the situation they attended. It also notes the difficulty in training staff for unexpected emergencies and the potential for improved control room measures.

Addressed to: HMP Styal; Ministry of Justice

1 response identified · 2 indexed addressees · Chief Coroner confirmed non-response

Darren Docherty

Report dated 14 Apr 2024 Reference 2024-0197

AI-generated concerns summaryThe coroner raised concerns that individuals released from prison often lack accommodation, which prevents them from accessing necessary GP and community mental health services.

Addressed to: HMP Stoke Health; Local Authority for Stoke on Trent

1 response identified · 2 indexed addressees · Chief Coroner confirmed non-response

Mark Kinzley

Report dated 26 Mar 2024 Reference 2024-0168

AI-generated concerns summaryConcerns included the appropriateness of Mr Kinzley's care location and the absence of a formal capacity assessment. Furthermore, no mental health assessment was initiated despite his history of mental illness, self-harm, and deteriorating condition.

Addressed to: London Borough of Redbridge; Cambridge Nursing Home Ltd; Evergreen Surgery; Integrated Care Board (ICB) for North-East London

2 responses identified · 4 indexed addressees · Chief Coroner confirmed non-response

Joshua Burgess

Report dated 13 Feb 2024 Reference 2024-0077

AI-generated concerns summaryLack of clear instructions from the neurology department to GPs regarding medication changes, combined with a GP surgery workflow that prevented clinicians from reviewing crucial correspondence. This resulted in difficulties for the care provider in administering the correct medication dosage.

Addressed to: Brook Medical Centre; Godfrey Care; University Hospitals of North Midlands NHS Trust

2 responses identified · 3 indexed addressees · Chief Coroner confirmed non-response

Mark Pryor

Report dated 6 Feb 2024 Reference 2024-0063

AI-generated concerns summaryThe coroner raised concerns that Health Care Professionals (HCPs) in police custody suites may not be receiving sufficient and adequate training to practice effectively or safely.

Addressed to: Department of Health and Social Care; HCRG Care Services Ltd; Ministry of Justice

2 responses identified · 3 indexed addressees · Chief Coroner confirmed non-response

Matthew Wickes

Report dated 19 Jan 2024 Reference 2024-0033

AI-generated concerns summaryThe coroner raised concerns about academic staff awareness and understanding of student mental health, noting non-compulsory training and insufficient guidance on identifying struggles, especially for neurodiverse students. A gap between academic assessment and pastoral support was also identified.

Addressed to: University of Southampton

0 responses identified · 1 indexed addressee · Chief Coroner confirmed non-response