PFD · Response tracker

PFD Response Tracker

1,407 total 0 with responses identified 0 with 0 responses identified (past 2 years) 0 response window open 1,407 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.

7 reports include a non-response confirmed by the Chief Coroner. Show only confirmed →

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1,407 reports · Page 1 of 29

Date ↓	Deceased	Addressee(s)	Responses identified
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
30 Aug 2024	Wendy Afford AI-generated concerns summaryThe coroner identified issues with skin integrity risk assessment and monitoring, incomplete repositioning records, and a lack of management oversight regarding care plan compliance and staff training in these areas.	Happy at Home Community Care Services Ltd	0 responses · 1 indexed addressees
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
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
16 Jul 2024	Glenn Jacques and Ben Whiteman and Callum Clark AI-generated concerns summaryThe coroner noted the railway station is perceived as a location for suicides, and recent incidents meet the British Transport Police's 'hot spot' definition, contrary to prior classifications.	Northern Rail	0 responses · 1 indexed addressees
27 Jun 2024	Paul Holmes AI-generated concerns summaryThe coroner noted a lack of clear and detailed handover between doctors during a patient's transfer, an unagreed treatment plan, and insufficient documentation. A prescription error also delayed the administration …	Cornwall Partnership NHS Foundation Trust Royal Cornwall Hospitals NHS Trust	0 responses · 2 indexed addressees
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
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
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
14 May 2024	James Pearson AI-generated concerns summaryThe coroner raised concerns regarding the lack of proper documented patient observations, which hindered the ability to track a patient's decline. There were also insufficient doctors on duty to manage …	University Hospitals Birmingham NHS Foundation	0 responses · 1 indexed addressees
23 Apr 2024	Emmanuel Ladapo AI-generated concerns summaryThe coroner noted insufficient engagement by C&I services with Mr Ladapo's family, and a psychiatrist omitted to ask about suicidal ideation during consultations despite noted deterioration. This indicates a gap …	Camden and Islington NHS Foundation Trust	0 responses · 1 indexed addressees
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
21 Dec 2023	Denise Porter AI-generated concerns summaryThe coroner raised concerns that Oxleas NHS Trust staff relied on an incomplete summary from a British Transport Police referral, failing to scrutinise the full report or make further inquiries. …	Oxleas NHS Foundation Trust	0 responses · 1 indexed addressees
20 Dec 2023	Shaun Parks AI-generated concerns summaryThe coroner noted the ambulance response time of 3 hours and 18 minutes likely affected the outcome. This was exacerbated by insufficient Emergency Medical Dispatchers, staffing levels below demand, and …	Department of Health and Social Care West Yorkshire Integrated Care System	0 responses · 2 indexed addressees
19 Dec 2023	Amanda Hitch AI-generated concerns summaryThematic clinical notes hindered the sharing of critical information, and structured risk management tools were not utilised. A multi-agency plan to alert care coordinators to railway station attendances was also …	British Transport Police Essex Partnership NHS Foundation Trust	0 responses · 2 indexed addressees
18 Dec 2023	David Hemmings AI-generated concerns summaryThe coroner noted that training provided to the manager and support worker regarding the movement of injured people was insufficient and unmemorable, leading to it being disregarded and risking worsened …	Choice Support	0 responses · 1 indexed addressees
8 Dec 2023	Jasbir Pahal AI-generated concerns summaryThe coroner notes the thrombectomy service for stroke patients operates only during limited weekday hours, denying access to this time-sensitive treatment for those suffering a stroke outside these times. This …	NHS England Stroke, East Kent Hospitals University NHS Foundation Trust West Yorkshire and Harrogate Integrated Stroke Delivery Network West Yorkshire Integrated Care Board Wirral University Teaching Hospital NHS Foundation Trust	0 responses · 5 indexed addressees
6 Dec 2023	Margaret Heal AI-generated concerns summaryA lack of evidence that an elderly patient living alone received clear instructions to resume anti-coagulation medication post-discharge raises questions about ensuring vulnerable patients are aware of critical advice.	The Trust	0 responses · 1 indexed addressees
4 Dec 2023	Fraser Moore AI-generated concerns summaryThe coroner identified that CCTV coverage at the station did not extend beyond the concourse and that footage was not immediately available to Route Control, despite the risk of incidents …	Department for Transport Network Rail	0 responses · 2 indexed addressees
30 Nov 2023	Julia Murphy AI-generated concerns summaryThe coroner identified inadequate falls prevention measures, including incomplete referral forms and a lack of escalation despite numerous falls. Concerns also related to insufficient care for a resident with evolving …	Abbey Wood Lodge Care Home	0 responses · 1 indexed addressees
27 Nov 2023	Boycie Chatterton AI-generated concerns summaryThe coroner notes that a properly managed and funded national register for Tracheo-Oesophageal Fistula (TOF) cases is absent, which experts stated would improve outcomes and survival rates.	Department of Health and Social Care NHS England	0 responses · 2 indexed addressees
20 Nov 2023	Susan Gladstone AI-generated concerns summaryThe coroner noted a lack of information for prescribing doctors regarding the known interaction between tramadol and warfarin, as this interaction is not listed in the British National Formulary.	NHS England	0 responses · 1 indexed addressees
13 Nov 2023	Bavaniammah Theiventhiran AI-generated concerns summaryThe coroner noted East Surrey Hospital is not meeting NICE guidelines for hip fracture surgery, with over half of patients experiencing delays beyond the recommended timeframe. This non-compliance was identified …	Surrey and Sussex Healthcare NHS Trust	0 responses · 1 indexed addressees
10 Nov 2023	Elizabeth Watson AI-generated concerns summaryThe coroner identified a lack of structured training for bridge staff in identifying and interacting with vulnerable individuals, including specific input from mental health professionals or negotiation skills. Concerns also …	Human Resources	0 responses · 1 indexed addressees
8 Nov 2023	Owen Garnett AI-generated concerns summaryThe coroner identified gaps in how carers' health and safety concerns were addressed and recorded, lacking clear staff guidance. There were also concerns that Owen's supervision deviated from his risk …	Health and Safety Executive Unity MAT	0 responses · 2 indexed addressees
7 Nov 2023	Michael Vincent AI-generated concerns summaryThe coroner noted a ten-hour ambulance response delay for an elderly individual after a fall, significantly missing the allocated target time. This prolonged 'long lie' risks terminal kidney injury and …	Association of Ambulance Chief Executives East of England Ambulance Service NHS Trust NHS England Royal College of Emergency Medicine	0 responses · 4 indexed addressees
7 Nov 2023	Irene White AI-generated concerns summaryFrome Nursing Home staff did not adequately assess or manage the risk of deep vein thrombosis for an immobile patient, lacking a DVT policy and failing to inquire about care …	Frome Nursing Home	0 responses · 1 indexed addressees
1 Nov 2023	Musa Konteh AI-generated concerns summaryThe coroner identified a lack of health and safety procedures for jet ski hire, including no instructions on emergency cut-off, avoiding dangerous areas, or the provision of lifejackets. Additionally, Foreign, …	Consular Feedback Team	0 responses · 1 indexed addressees
27 Oct 2023	Geoffrey Whatling AI-generated concerns summaryConcerns included incomplete food and fluid charts and observations not taken hourly or fully logged in care records. Emergency services were not called for a high NEWS2 score, and 111 …	Amberley Hall Care Home Athena Care Homes (UK) Limited	0 responses · 2 indexed addressees
25 Oct 2023	Federica Cavenati AI-generated concerns summaryThe coroner noted the absence of intravenous antidepressant medication in the United Kingdom for patients unable to take oral medication, despite its availability in Europe.	Medicines and Healthcare products Regulatory Agency	0 responses · 1 indexed addressees
19 Oct 2023	Wayne Milne AI-generated concerns summaryThe practice had an inconsistent 999 calling procedure where nursing staff were not required to call for life-threatening conditions, leading to delayed urgent medical assistance. There was also a lack …	Rocky Lane Medical Centre	0 responses · 1 indexed addressees
6 Oct 2023	Adam Stuyvesant AI-generated concerns summaryThe DVT risk assessment in the Emergency Department at The Great Western Hospital did not account for lower limb immobility caused by plastic boots when considering anti-clotting medication. This gap …	Great Western Hospital	0 responses · 1 indexed addressees
29 Sep 2023	Leighton Dickens AI-generated concerns summaryThe coroner raised concerns about police officers having limited access to readily available, clinically qualified mental health advice and patient records after the withdrawal of triage support, with no clear …	South Wales Police	0 responses · 1 indexed addressees
29 Sep 2023	Douglas Nickols AI-generated concerns summaryThe coroner notes that East Surrey Hospital's inability to perform hip fracture operations within the NICE guideline timeframe (on the day of admission or the day thereafter) places patients at …	Surrey and Sussex Healthcare NHS Trust	0 responses · 1 indexed addressees
29 Sep 2023	Marion Luckraft AI-generated concerns summaryDelays in diagnosis, treatment, and care escalation, alongside fragmented care across two Trust sites, probably increased the risk of biliary sepsis due to an unclear treatment pathway.	Barking, Havering and Redbridge University Trust	0 responses · 1 indexed addressees
26 Sep 2023	Benjamin Hazelden AI-generated concerns summaryThe coroner noted a severe lack of suitable specialist placements and beds for young adults with autism who are at risk of self-harm or harm to others, leading to an …	NHS England NHS Kent and Medway Clinical Commissioning Group	0 responses · 2 indexed addressees
19 Sep 2023	Lauren Bridges AI-generated concerns summaryThe coroner noted an omission to update the Hospital Overview correctly and timeously, and a lack of documentation regarding discussions about patient repatriation to an available bed.	Dorset Healthcare University NHS Foundation Trust	0 responses · 1 indexed addressees
16 Sep 2023	Sienna Monterio AI-generated concerns summaryThe coroner noted that the blood gas analyser was not set to analyse haemoglobin level at birth, preventing consideration of other possible causes for a baby's condition. There is a …	National Institution for Health and Care Excellence Royal College of Obstetricians and Gynaecologists Royal College of Paediatrics and Child Health	0 responses · 3 indexed addressees
15 Sep 2023	Eclipse Morrison AI-generated concerns summaryConcerns include the failure to identify risk factors in high-risk pregnancies, leading to insufficient consideration of elective Caesarean Sections. The coroner also noted gaps in training and escalation processes for …	Department of Health and Social Care George Eliot Hospital NHS Trust National Institute for Health and Care Excellence Royal College of Midwives Royal College of Obstetricians and Gynaecologists	0 responses · 5 indexed addressees
8 Sep 2023	Kristopher Tilbury AI-generated concerns summaryThe coroner identified persistent issues with the widespread availability of illicit drugs, including synthetic cannabinoids, at HMP The Mount. Reports from inspections and monitoring boards consistently noted weak drug supply …	HMP The Mount Ministry of Justice	0 responses · 2 indexed addressees
6 Sep 2023	James Jones AI-generated concerns summaryThe coroner raised concerns about continued pressures within the Accident and Emergency department at Ysbyty Gwynedd, potentially leading to doctors missing target review times for patients and insufficient staffing levels …	Betsi Cadwaladr University Health Board	0 responses · 1 indexed addressees
25 Aug 2023	Miss C AI-generated concerns summaryThe coroner noted the need for a review of policies concerning the out-of-hours availability of Resuscitation Officers by the Resuscitation Council UK and NGH NHS Trust.	Northampton General Hospital Trust Resuscitation Council UK	0 responses · 2 indexed addressees
24 Aug 2023	Jonathan Mann and Margaret Costa AI-generated concerns summaryThe D&D cell did not obtain critical information regarding the pilot or plane's capabilities, nor the weather at the diversion aerodrome. A lack of checklists and miscommunications limited the ability …	Civil Aviation Authority Military Aviation Authority	0 responses · 2 indexed addressees
2 Aug 2023	Dumile Thompson AI-generated concerns summaryInsufficient national guidance and training on angioedema types meant clinicians lacked awareness of ACE Inhibitor angioedema complexity and treatment pathways. The BNF also lacked information on racial disparities and alternative …	NHS England NHS National Patient Safety Alerting Committee	0 responses · 2 indexed addressees
21 Jul 2023	Steven Duquemin AI-generated concerns summaryInconsistent care records indicated a service user was not at risk of choking when they clearly were, and a senior manager demonstrated an under-appreciation of this risk. This approach could …	Northern Care Limited	0 responses · 1 indexed addressees
20 Jul 2023	Andrew Vizard AI-generated concerns summaryThe coroner identified delays in emergency response for an unresponsive patient, specifically concerning the time taken to obtain monitoring equipment, for a doctor to attend, and to call an ambulance. …	Nottingham Healthcare Trust	0 responses · 1 indexed addressees
18 Jul 2023	Philip Hawkins AI-generated concerns summaryThe coroner noted significant delays in allocating a bed upon hospital entry, insufficient nursing and clinical staff, and gaps in nursing documentation and communication of patient status within the Emergency …	Betsi Cadwaladr University Health Board Welsh Ambulance Service Trust	0 responses · 2 indexed addressees
6 Jul 2023	Emlyn Roberts AI-generated concerns summarySignificant and unacceptable delays in ambulance attendance have worsened over ten years, the coroner noted. There is also inadequate cohesive planning for both short-term pressures and long-term solutions to address …	Betsi Cadwaladr University Health Board, Welsh Ambulance Service Trust, North Wales Local Authorities	0 responses · 1 indexed addressees
29 Jun 2023	Matthew Phipps AI-generated concerns summaryThe coroner noted the lack of a contingency plan and standard operating procedures for managing a full Intensive Care Unit, which meant a patient needing intensive care could not be …	Barking, Havering and Redbridge University Hospital NHS Foundation Trust	0 responses · 1 indexed addressees
29 Jun 2023	Clinton Fear AI-generated concerns summaryThe coroner raises concerns about the inconsistency between NHS guidance for notifying patients of Mycobacterium Chimaera infection risk (from January 2013) and evidence of infections occurring significantly earlier, which may …	UK Health Security Agency	0 responses · 1 indexed addressees

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

Wendy Afford

Report dated 30 Aug 2024 Reference 2024-0478

AI-generated concerns summaryThe coroner identified issues with skin integrity risk assessment and monitoring, incomplete repositioning records, and a lack of management oversight regarding care plan compliance and staff training in these areas.

Addressed to: Happy at Home Community Care Services Ltd

0 responses identified · 1 indexed addressee

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

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

Glenn Jacques and Ben Whiteman and Callum Clark

Report dated 16 Jul 2024 Reference 2024-0376

AI-generated concerns summaryThe coroner noted the railway station is perceived as a location for suicides, and recent incidents meet the British Transport Police's 'hot spot' definition, contrary to prior classifications.

Addressed to: Northern Rail

0 responses identified · 1 indexed addressee

Paul Holmes

Report dated 27 Jun 2024 Reference 2024-0344

AI-generated concerns summaryThe coroner noted a lack of clear and detailed handover between doctors during a patient's transfer, an unagreed treatment plan, and insufficient documentation. A prescription error also delayed the administration of hydrating fluids.

Addressed to: Cornwall Partnership NHS Foundation Trust; Royal Cornwall Hospitals NHS Trust

0 responses identified · 2 indexed addressees

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

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

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

James Pearson

Report dated 14 May 2024 Reference 2024-0266

AI-generated concerns summaryThe coroner raised concerns regarding the lack of proper documented patient observations, which hindered the ability to track a patient's decline. There were also insufficient doctors on duty to manage more than one critically unwell patient, and potential delays in obtaining blood products stored outside the ED.

Addressed to: University Hospitals Birmingham NHS Foundation

0 responses identified · 1 indexed addressee

Emmanuel Ladapo

Report dated 23 Apr 2024 Reference 2024-0215

AI-generated concerns summaryThe coroner noted insufficient engagement by C&I services with Mr Ladapo's family, and a psychiatrist omitted to ask about suicidal ideation during consultations despite noted deterioration. This indicates a gap in staff awareness regarding the importance of exploring suicidal feelings.

Addressed to: Camden and Islington NHS Foundation Trust

0 responses identified · 1 indexed addressee

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

Denise Porter

Report dated 21 Dec 2023 Reference 2023-0548

AI-generated concerns summaryThe coroner raised concerns that Oxleas NHS Trust staff relied on an incomplete summary from a British Transport Police referral, failing to scrutinise the full report or make further inquiries. This led to an inadequate risk assessment and a missed opportunity to implement a more robust care plan.

Addressed to: Oxleas NHS Foundation Trust

0 responses identified · 1 indexed addressee

Shaun Parks

Report dated 20 Dec 2023 Reference 2023-0538

AI-generated concerns summaryThe coroner noted the ambulance response time of 3 hours and 18 minutes likely affected the outcome. This was exacerbated by insufficient Emergency Medical Dispatchers, staffing levels below demand, and significant delays in offloading patients at hospitals.

Addressed to: Department of Health and Social Care; West Yorkshire Integrated Care System

0 responses identified · 2 indexed addressees

Amanda Hitch

Report dated 19 Dec 2023 Reference 2023-0535

AI-generated concerns summaryThematic clinical notes hindered the sharing of critical information, and structured risk management tools were not utilised. A multi-agency plan to alert care coordinators to railway station attendances was also ineffective, particularly for unstaffed stations.

Addressed to: British Transport Police; Essex Partnership NHS Foundation Trust

0 responses identified · 2 indexed addressees

David Hemmings

Report dated 18 Dec 2023 Reference 2023-0529

AI-generated concerns summaryThe coroner noted that training provided to the manager and support worker regarding the movement of injured people was insufficient and unmemorable, leading to it being disregarded and risking worsened injuries.

Addressed to: Choice Support

0 responses identified · 1 indexed addressee

Jasbir Pahal

Report dated 8 Dec 2023 Reference 2023-0509

AI-generated concerns summaryThe coroner notes the thrombectomy service for stroke patients operates only during limited weekday hours, denying access to this time-sensitive treatment for those suffering a stroke outside these times. This creates a disparity in access based on when a stroke occurs.

Addressed to: NHS England; Stroke, East Kent Hospitals University NHS Foundation Trust; West Yorkshire and Harrogate Integrated Stroke Delivery Network; West Yorkshire Integrated Care Board; Wirral University Teaching Hospital NHS Foundation Trust

0 responses identified · 5 indexed addressees

Margaret Heal

Report dated 6 Dec 2023 Reference 2024-0368

AI-generated concerns summaryA lack of evidence that an elderly patient living alone received clear instructions to resume anti-coagulation medication post-discharge raises questions about ensuring vulnerable patients are aware of critical advice.

Addressed to: The Trust

0 responses identified · 1 indexed addressee

Fraser Moore

Report dated 4 Dec 2023 Reference 2023-0497

AI-generated concerns summaryThe coroner identified that CCTV coverage at the station did not extend beyond the concourse and that footage was not immediately available to Route Control, despite the risk of incidents at busy stations.

Addressed to: Department for Transport; Network Rail

0 responses identified · 2 indexed addressees

Julia Murphy

Report dated 30 Nov 2023 Reference 2023-0490

AI-generated concerns summaryThe coroner identified inadequate falls prevention measures, including incomplete referral forms and a lack of escalation despite numerous falls. Concerns also related to insufficient care for a resident with evolving dementia and a lack of staff training in falls prevention.

Addressed to: Abbey Wood Lodge Care Home

0 responses identified · 1 indexed addressee

Boycie Chatterton

Report dated 27 Nov 2023 Reference 2023-0483

AI-generated concerns summaryThe coroner notes that a properly managed and funded national register for Tracheo-Oesophageal Fistula (TOF) cases is absent, which experts stated would improve outcomes and survival rates.

Addressed to: Department of Health and Social Care; NHS England

0 responses identified · 2 indexed addressees

Susan Gladstone

Report dated 20 Nov 2023 Reference 2023-0485

AI-generated concerns summaryThe coroner noted a lack of information for prescribing doctors regarding the known interaction between tramadol and warfarin, as this interaction is not listed in the British National Formulary.

Addressed to: NHS England

0 responses identified · 1 indexed addressee

Bavaniammah Theiventhiran

Report dated 13 Nov 2023 Reference 2023-0444

AI-generated concerns summaryThe coroner noted East Surrey Hospital is not meeting NICE guidelines for hip fracture surgery, with over half of patients experiencing delays beyond the recommended timeframe. This non-compliance was identified as potentially placing patients at risk of early death.

Addressed to: Surrey and Sussex Healthcare NHS Trust

0 responses identified · 1 indexed addressee

Elizabeth Watson

Report dated 10 Nov 2023 Reference 2023-0439

AI-generated concerns summaryThe coroner identified a lack of structured training for bridge staff in identifying and interacting with vulnerable individuals, including specific input from mental health professionals or negotiation skills. Concerns also covered delays in emergency service response for vulnerable persons.

Addressed to: Human Resources

0 responses identified · 1 indexed addressee

Owen Garnett

Report dated 8 Nov 2023 Reference 2023-0434

AI-generated concerns summaryThe coroner identified gaps in how carers' health and safety concerns were addressed and recorded, lacking clear staff guidance. There were also concerns that Owen's supervision deviated from his risk assessment without clear guidelines for teachers.

Addressed to: Health and Safety Executive; Unity MAT

0 responses identified · 2 indexed addressees

Michael Vincent

Report dated 7 Nov 2023 Reference 2023-0432

AI-generated concerns summaryThe coroner noted a ten-hour ambulance response delay for an elderly individual after a fall, significantly missing the allocated target time. This prolonged 'long lie' risks terminal kidney injury and death for frail, elderly individuals, necessitating a review of emergency call management.

Addressed to: Association of Ambulance Chief Executives; East of England Ambulance Service NHS Trust; NHS England; Royal College of Emergency Medicine

0 responses identified · 4 indexed addressees

Irene White

Report dated 7 Nov 2023 Reference 2023-0430

AI-generated concerns summaryFrome Nursing Home staff did not adequately assess or manage the risk of deep vein thrombosis for an immobile patient, lacking a DVT policy and failing to inquire about care needs or implement preventative measures.

Addressed to: Frome Nursing Home

0 responses identified · 1 indexed addressee

Musa Konteh

Report dated 1 Nov 2023 Reference 2023-0426

AI-generated concerns summaryThe coroner identified a lack of health and safety procedures for jet ski hire, including no instructions on emergency cut-off, avoiding dangerous areas, or the provision of lifejackets. Additionally, Foreign, Commonwealth and Development Office travel advice does not explicitly state that safety standards may be lower than in the UK.

Addressed to: Consular Feedback Team

0 responses identified · 1 indexed addressee

Geoffrey Whatling

Report dated 27 Oct 2023 Reference 2023-0418

AI-generated concerns summaryConcerns included incomplete food and fluid charts and observations not taken hourly or fully logged in care records. Emergency services were not called for a high NEWS2 score, and 111 call takers were not informed of it.

Addressed to: Amberley Hall Care Home; Athena Care Homes (UK) Limited

0 responses identified · 2 indexed addressees

Federica Cavenati

Report dated 25 Oct 2023 Reference 2023-0410

AI-generated concerns summaryThe coroner noted the absence of intravenous antidepressant medication in the United Kingdom for patients unable to take oral medication, despite its availability in Europe.

Addressed to: Medicines and Healthcare products Regulatory Agency

0 responses identified · 1 indexed addressee

Wayne Milne

Report dated 19 Oct 2023 Reference 2023-0393

AI-generated concerns summaryThe practice had an inconsistent 999 calling procedure where nursing staff were not required to call for life-threatening conditions, leading to delayed urgent medical assistance. There was also a lack of awareness about Dissecting Aortic Aneurysm and no action taken by the practice following these events.

Addressed to: Rocky Lane Medical Centre

0 responses identified · 1 indexed addressee

Adam Stuyvesant

Report dated 6 Oct 2023 Reference 2023-0372

AI-generated concerns summaryThe DVT risk assessment in the Emergency Department at The Great Western Hospital did not account for lower limb immobility caused by plastic boots when considering anti-clotting medication. This gap could result in other patients developing deep vein thrombosis leading to pulmonary embolus.

Addressed to: Great Western Hospital

0 responses identified · 1 indexed addressee

Leighton Dickens

Report dated 29 Sep 2023 Reference 2023-0367

AI-generated concerns summaryThe coroner raised concerns about police officers having limited access to readily available, clinically qualified mental health advice and patient records after the withdrawal of triage support, with no clear timeline for the intended replacement service.

Addressed to: South Wales Police

0 responses identified · 1 indexed addressee

Douglas Nickols

Report dated 29 Sep 2023 Reference 2023-0354

AI-generated concerns summaryThe coroner notes that East Surrey Hospital's inability to perform hip fracture operations within the NICE guideline timeframe (on the day of admission or the day thereafter) places patients at increased risk of complications and early death.

Addressed to: Surrey and Sussex Healthcare NHS Trust

0 responses identified · 1 indexed addressee

Marion Luckraft

Report dated 29 Sep 2023 Reference 2023-0355

AI-generated concerns summaryDelays in diagnosis, treatment, and care escalation, alongside fragmented care across two Trust sites, probably increased the risk of biliary sepsis due to an unclear treatment pathway.

Addressed to: Barking, Havering and Redbridge University Trust

0 responses identified · 1 indexed addressee

Benjamin Hazelden

Report dated 26 Sep 2023 Reference 2024-0026

AI-generated concerns summaryThe coroner noted a severe lack of suitable specialist placements and beds for young adults with autism who are at risk of self-harm or harm to others, leading to an unsuitable hospital stay and limited options for urgent care.

Addressed to: NHS England; NHS Kent and Medway Clinical Commissioning Group

0 responses identified · 2 indexed addressees

Lauren Bridges

Report dated 19 Sep 2023 Reference 2023-0466

AI-generated concerns summaryThe coroner noted an omission to update the Hospital Overview correctly and timeously, and a lack of documentation regarding discussions about patient repatriation to an available bed.

Addressed to: Dorset Healthcare University NHS Foundation Trust

0 responses identified · 1 indexed addressee

Sienna Monterio

Report dated 16 Sep 2023 Reference 2023-0344

AI-generated concerns summaryThe coroner noted that the blood gas analyser was not set to analyse haemoglobin level at birth, preventing consideration of other possible causes for a baby's condition. There is a lack of clarity and inconsistent national practice regarding this, raising a risk of preventable deaths.

Addressed to: National Institution for Health and Care Excellence; Royal College of Obstetricians and Gynaecologists; Royal College of Paediatrics and Child Health

0 responses identified · 3 indexed addressees

Eclipse Morrison

Report dated 15 Sep 2023 Reference 2023-0334

AI-generated concerns summaryConcerns include the failure to identify risk factors in high-risk pregnancies, leading to insufficient consideration of elective Caesarean Sections. The coroner also noted gaps in training and escalation processes for junior doctors regarding appropriate mode and timing of birth decisions.

Addressed to: Department of Health and Social Care; George Eliot Hospital NHS Trust; National Institute for Health and Care Excellence; Royal College of Midwives; Royal College of Obstetricians and Gynaecologists

0 responses identified · 5 indexed addressees

Kristopher Tilbury

Report dated 8 Sep 2023 Reference 2023-0331Deceased

AI-generated concerns summaryThe coroner identified persistent issues with the widespread availability of illicit drugs, including synthetic cannabinoids, at HMP The Mount. Reports from inspections and monitoring boards consistently noted weak drug supply reduction efforts and easy access to substances, impacting prisoner safety.

Addressed to: HMP The Mount; Ministry of Justice

0 responses identified · 2 indexed addressees

James Jones

Report dated 6 Sep 2023 Reference 2023-0320

AI-generated concerns summaryThe coroner raised concerns about continued pressures within the Accident and Emergency department at Ysbyty Gwynedd, potentially leading to doctors missing target review times for patients and insufficient staffing levels to safely meet demand.

Addressed to: Betsi Cadwaladr University Health Board

0 responses identified · 1 indexed addressee

Miss C

Report dated 25 Aug 2023 Reference 2023-0309

AI-generated concerns summaryThe coroner noted the need for a review of policies concerning the out-of-hours availability of Resuscitation Officers by the Resuscitation Council UK and NGH NHS Trust.

Addressed to: Northampton General Hospital Trust; Resuscitation Council UK

0 responses identified · 2 indexed addressees

Jonathan Mann and Margaret Costa

Report dated 24 Aug 2023 Reference 2023-0307

AI-generated concerns summaryThe D&D cell did not obtain critical information regarding the pilot or plane's capabilities, nor the weather at the diversion aerodrome. A lack of checklists and miscommunications limited the ability to provide adequate assistance to the pilot.

Addressed to: Civil Aviation Authority; Military Aviation Authority

0 responses identified · 2 indexed addressees

Dumile Thompson

Report dated 2 Aug 2023 Reference 2023-0281

AI-generated concerns summaryInsufficient national guidance and training on angioedema types meant clinicians lacked awareness of ACE Inhibitor angioedema complexity and treatment pathways. The BNF also lacked information on racial disparities and alternative medications.

Addressed to: NHS England; NHS National Patient Safety Alerting Committee

0 responses identified · 2 indexed addressees

Steven Duquemin

Report dated 21 Jul 2023 Reference 2023-0272

AI-generated concerns summaryInconsistent care records indicated a service user was not at risk of choking when they clearly were, and a senior manager demonstrated an under-appreciation of this risk. This approach could prevent necessary preventative measures from being implemented for vulnerable service users.

Addressed to: Northern Care Limited

0 responses identified · 1 indexed addressee

Andrew Vizard

Report dated 20 Jul 2023 Reference 2023-0273

AI-generated concerns summaryThe coroner identified delays in emergency response for an unresponsive patient, specifically concerning the time taken to obtain monitoring equipment, for a doctor to attend, and to call an ambulance. Existing staff training and emergency response systems may not ensure an immediate and effective response in such situations.

Addressed to: Nottingham Healthcare Trust

0 responses identified · 1 indexed addressee

Philip Hawkins

Report dated 18 Jul 2023 Reference 2023-0248

AI-generated concerns summaryThe coroner noted significant delays in allocating a bed upon hospital entry, insufficient nursing and clinical staff, and gaps in nursing documentation and communication of patient status within the Emergency Department.

Addressed to: Betsi Cadwaladr University Health Board; Welsh Ambulance Service Trust

0 responses identified · 2 indexed addressees

Emlyn Roberts

Report dated 6 Jul 2023 Reference 2023-0229

AI-generated concerns summarySignificant and unacceptable delays in ambulance attendance have worsened over ten years, the coroner noted. There is also inadequate cohesive planning for both short-term pressures and long-term solutions to address these multifactorial delays.

Addressed to: Betsi Cadwaladr University Health Board, Welsh Ambulance Service Trust, North Wales Local Authorities

0 responses identified · 1 indexed addressee

Matthew Phipps

Report dated 29 Jun 2023 Reference 2023-0219

AI-generated concerns summaryThe coroner noted the lack of a contingency plan and standard operating procedures for managing a full Intensive Care Unit, which meant a patient needing intensive care could not be admitted.

Addressed to: Barking, Havering and Redbridge University Hospital NHS Foundation Trust

0 responses identified · 1 indexed addressee

Clinton Fear

Report dated 29 Jun 2023 Reference 2023-0286

AI-generated concerns summaryThe coroner raises concerns about the inconsistency between NHS guidance for notifying patients of Mycobacterium Chimaera infection risk (from January 2013) and evidence of infections occurring significantly earlier, which may lead to delayed diagnosis and harm for affected patients.

Addressed to: UK Health Security Agency

0 responses identified · 1 indexed addressee