NHS England
Coroner Alison Mutch · Manchester South
No published response from this organisation found.
Coroner Alison Mutch · Manchester South
No published response from this organisation found.
Coroner Carly Henley · Newcastle upon Tyne and North Tyneside
No published response from this organisation found.
Coroner Anton van Dellen · West London · in 2 recurrence links
Response · 1 stated action
2023-0362-Response-from-NHSE.pdf ↗“NHS England is the responsible organisation for the commissioning of healthcare into prisons, which is devolved to regional teams. Commissioning healthcare in prisons is done on a principle of equivalence, which has been defined by the Royal College of General Practitioners (RCGP) and has been adopted by the National Prison Partnership Board1. The definition broadly states the aim is to ensure people detained in prisons in England, are offered provision of and access to appropriate services and”
Coroner Catherine Wood · North East Kent · in 3 recurrence links
No published response from this organisation found.
Coroner Samantha Goward · Cambridgeshire and Peterborough · in 1 recurrence link
Response · 1 stated action
2023-0349-Response-from-NHS-England.pdf ↗“In recent years, significant work has been undertaken to raise awareness within acute care settings of the indicators of acute aortic dissection, following recommendations made by the Healthcare Safety Investigations Branch (HSIB) in January 2020 on the culmination of an investigation into delayed recognition of acute aortic dissection and an acknowledgement that there have been challenges in frontline staff diagnosis and treatment of acute aortic dissection. This included the Manchester Triage”
Coroner Andrew Bridgman · Manchester South · in 4 recurrence links
Response · 1 stated action
2023-0438-Response-from-NHS-England.pdf ↗“All Integrated Care Boards (ICBs) were asked to work towards eliminating the practice in NHS England's 2023/24 Priorities and Operational Planning Guidance.”
Response · 6 stated actions
2023-0438-Response-from-Dorset-Healthcare-University-NHS-Foundation-Trust.pdf ↗“The Trust has undertaken a comprehensive review to ensure that all patients who are receiving acute care funded by the Trust in Out of Area beds are accurately identified as such on our clinical system.”
“We have enhanced the daily Hospital Overview situation report which is accurate at the point it is sent, with the purpose of providing a summary at the start of the working day across the organisation to key colleagues including senior clinicians and managers.”
“In addition, the Trust has also added a specific section to the daily Hospital Overview template showing patients who are in out of area beds who require repatriation to a local bed.”
“We have updated the electronic admission form template that is embedded in the patient record system so that when a patient requires admission, we capture more robust information, which is then also reportable in a bed state automated report.”
“The Trust has implemented a new Standard Operating Procedure (SOP) for Enabling Purposeful Admissions. This clearly sets out the required process, roles and responsibilities of key staff and the required recording in respect of inpatient flow decisions.”
“We have reviewed our daily clinical meeting that takes place in respect of bed flow and set out requirements in the meeting's terms of reference, including standard items for discussion and recording standards.”
Coroner Catherine Wood · Central and South East Kent
No published response from this organisation found.
- Riya Hirani: Prevention of future deaths report15 Sept 2023
Coroner Mary Hassell · Inner North London
Response · 1 stated action
2023-0339-Response-from-London-North-West-University-Healthcare.pdf ↗“Point of care testing is now fully operational within our emergency pathway for measuring and assessing Streptococcus A and respiratory illness in children.”
Response · 1 stated action
2023-0339-Response-from-London-North-West-University-Healthcare-NHS-Trust.pdf ↗“Point of care testing is now fully operational within our emergency pathway for measuring and assessing Streptococcus A and respiratory illness in children.”
Coroner Robert Simpson · Hampshire, Portsmouth and Southampton · in 2 recurrence links
No published response from this organisation found.
Coroner Andrew Harris · Inner South London
No published response from this organisation found.
Coroner Simon Brenchley · Birmingham and Solihull
No published response from this organisation found.
Coroner Nadia Persaud · East London · in 1 recurrence link
Response · 4 stated actions
2023-0313-Response-from-North-East-London-Integrated-Care-Board.pdf ↗“We are developing a business case to secure additional funding to support improved resourcing of CAMHS services within NELFT.”
“The business case will also include requirements to implement a face to face approach for initial CAMHS assessments.”
“Recruitment of consultant psychiatrists is a national issue which we recognise locally - NHS North East London is working with NELFT and other providers to support recruitment and looking at innovative ways of recruiting. This work is being led by our Chief People and Culture Officer,”
“In the short term for CAHMS for NELFT we have developed a business case for more funding to support this demand.”
Response · 1 stated action
2023-0313-Response-from-North-East-London-Foundation-Trust.pdf ↗“The Trust is determined to ensure that all patients receive care in a person-centred approach and that the patient's voice is at the centre of planning the patient's care. The Trust's expectation is that the young person's voice is heard in the triage, initial assessment, care/treatment plan, and follow-ups alongside their parents / responsible adults.”
Coroner Andrew Harris · Inner South London
No published response from this organisation found.
Coroner Katy Thorne · Berkshire
No published response from this organisation found.
Coroner Tom Osborne · Milton Keynes
No published response from this organisation found.
Coroner Abigail Combes · South Yorkshire (West District) · in 9 recurrence links
Response · 3 stated actions
2025-0402-Response-from-DHSC.pdf ↗“In addition, all North East & Yorkshire systems have been asked for assurance that national guidance is being followed.”
“Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25.”
“In 2023/24, average Category 2 ambulance response times (including for serious conditions such as heart attacks and strokes) were over 13 minutes faster compared to the previous year, a reduction of 27%.”
Response · 1 stated action
2025-0402-Response-from-NHS-England.pdf ↗“NHS England has undertaken or been involved in several initiatives and activities around imaging reports to improve processes across Trusts and stakeholder organisations”
Coroner Christopher Wilkinson · Hampshire, Portsmouth and Southampton · in 1 recurrence link
Response · 1 stated action
2023-0507-Response-from-NHS-England.pdf ↗“As part of the NHS Long Term Plan, all systems in England have been receiving significant funding from 2021/22 to develop and roll out new models of integrated primary and community mental health care in line with the Community Mental Health Framework for the improved support of adults with severe mental illness in their community and to integrate mental, physical and social care. A key requirement of the new model of care is the provision of a dedicated community mental health offer for those with”
Coroner Graeme Irvine · East London · in 1 recurrence link
No published response from this organisation found.
Coroner Alison Mutch · Manchester South · in 1 recurrence link
Response · 1 stated action
2023-0262-Response-from-NHS-England.pdf ↗“NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all ambulance call categories than before the pandemic, as well as issues associated with handing over ambulance patients in a timely way including the flow of patients in and out of some NHS Trusts. That is why NHS England are focusing on improving ambulance performance for 2023/24, supported by the Delivery plan for recovering urgent and emergency care”
Coroner Alison Mutch · Manchester South · in 2 recurrence links
No published response from this organisation found.
Coroner Alison Mutch · Manchester South · in 1 recurrence link
No published response from this organisation found.
Coroner James Bennett · Birmingham and Solihull · in 5 recurrence links
Response · 3 stated actions
2023-0244-Response-from-NHS-England.pdf ↗“The NHS is working to further improve this capability to enable information to be automatically added into the GP [name redacted] record as appropriate.”
“medication. The dispensing notification used by pharmacies is for payment purposes and does not link back to the prescribing system. It is not used consistently by pharmacies as some use the notification system for when an item has been dispensed and is ready for collection, meaning the patient has not yet collected the medication and in fact may not collect it. Therefore, the system would not be a reliable way for the GP to check the patient's compliance with medication as there is no confirmation on”
“In June this year, the NHS published its Long Term Workforce Plan, setting out how we will ensure that staffing is put on a sustainable footing over the next fifteen years to improve patient care.”
Coroner Penelope Schofield · West Sussex · in 1 recurrence link
No published response from this organisation found.
Coroner Kevin McLoughlin · West Yorkshire (Eastern) · in 1 recurrence link
No published response from this organisation found.