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recurance

NHS England

548
reports received
153
with a published response found
69
recurrence chains
199
reports in those chains
  • David Jukes12 Jul 2019

    Coroner Emma Brown · Birmingham and Solihull · in 5 recurrence links

    Response · 6 stated actions
    2019-0220-Response-by-NHS-England.pdf ↗
    “NHS England and NHS Improvement will work with police forces to ensure that all relevant information from a police perspective is given to the liaison and diversion practitioner, including the nature of the detained person's presentation at the point of arrest, if relevant.”
    “We will commit to a national event by the end of March 2020 to debrief on this matter and any other information sharing/exchange issues that have been raised in other reports.”
    “High quality care for all, now and for future generations”
    “Connect will be available in custody”
    “three liaison and diversion teams will have access to partitioned parts of the police system that helps them understand the context of the persons arrival into custody and more information about historical custody appearances.”
    “All liaison and diversion teams have had information sharing training and this training offer has also been made to Police Healthcare providers”
  • Allan Davies9 Jul 2019

    Coroner James Bennett · Birmingham and Solihull

    Response · 1 stated action
    2019-0291-Response-by-NHS-England.pdf ↗
    “ensure they have robust clinical oversight in place in control rooms to monitor self-harm and suicidal patients safely and effectively, particularly those who have been allocated a Category 3 or 4 response initially”
  • Jennifer Withey3 Jul 2019

    Coroner Andrew Cox · Cornwall and the Isles of Scilly

    Response
    Response · 1 stated action
    2019-0225-Response-by-NHS-Digital.pdf ↗
    “The free text box could be set up so that identified symptoms, where appropriate, could generate an automatic red flag. By way of illustration, a non-blanching rash could automatically justify immediate hospital admission by ambulance in a case of suspected meningitis. Similarly, in this case, where a number of sepsis indicators were present, a red flag could have been raised requiring the call advisor specifically to consider a sepsis pathway. This would act as a second level of security, the first”
  • Andrew McCall1 Jul 2019

    Coroner Andrew Barkley · Stoke-on-Trent & North Staffordshire

    No published response from this organisation found.

  • Lewis Doyle24 Jun 2019

    Coroner Andre Rebello · Liverpool · in 1 recurrence link

    No published response from this organisation found.

  • Coroner Ian Arrow · Plymouth, Torbay and South Devon

    No published response from this organisation found.

  • Coroner Laurinda Bower · Nottinghamshire · in 2 recurrence links

    Response · 1 stated action
    2019-0149-Response-by-NHS-Digital.pdf ↗
    “call handlers receive significant training in questioning and listening skills during initial core training and through ongoing training updates. This is supported and monitored through monthly call audit. This training and on-going monthly call audit are all mapped to the NHS Pathways Competencies.”
  • Mildred Clark25 Apr 2019

    Coroner Sonia Hayes · Kent (North-East)

    No published response from this organisation found.

  • Ronald Clark8 Apr 2019

    Coroner David Clark · Portsmouth and South East Hampshire

    Response · 1 stated action
    2019-0151-Response-by-NHS-England.pdf ↗
    “The National Patient Safety Team, being part of NHS Improvement, is in the process of reviewing the National Safety Standards for Invasive Procedures (NatSIPPs).”
  • Tarek Chowdhury2 Apr 2019

    Coroner Richard Furniss · London (West) · in 1 recurrence link

    No published response from this organisation found.

  • Mohammed Ahmed19 Mar 2019

    Coroner Jacqueline Devonish · Suffolk

    No published response from this organisation found.

  • Coroner Alan Moore · Cheshire

    No published response from this organisation found.

  • Peter Garvin27 Feb 2019

    Coroner Fiona Wilcox · London Inner (West)

    No published response from this organisation found.

  • Terrence Smith21 Feb 2019

    Coroner Richard Travers · Surrey · in 1 recurrence link

    No published response from this organisation found.

  • Anthony Watson12 Feb 2019

    Coroner James Bennett · Birmingham and Solihull · in 5 recurrence links

    Response · 1 stated action
    2019-0044-Response-by-NHS-England.pdf ↗
    “NHS. England has committed to eliminating. the practice. of sending people out of-area for non-specialist acute inpatient:care due to”
  • Sophie Holman29 Jan 2019

    Coroner Shirley Radcliffe · London (East) · in 2 recurrence links

    Response · 1 stated action
    2019-0035-Response-by-NHS-England.pdf ↗
    “we will include a review of national asthma policy and existing clinical guidelines, including the 2014 NRAD (National Review of Asthma Deaths) report', in order to determine appropriate actions to be taken on both a national and local level to establish better consistency”
  • David Squire25 Jan 2019

    Coroner Emma Serrano · Black Country · in 1 recurrence link

    No published response from this organisation found.

  • Elizabeth Curtis11 Jan 2019

    Coroner Maria Voisin · Avon

    No published response from this organisation found.

  • Kirsty Walker19 Dec 2018

    Coroner Anna Crawford · Surrey · in 1 recurrence link

    Response · 1 stated action
    2018-0396-Response-by-NHS-England.pdf ↗
    “The next audit is currently underway, based on a census date of 28 February 2019. It is anticipated that the report will be available by the end of May 2019.”
  • John Delahaye18 Dec 2018

    Coroner Emma Brown · Birmingham and Solihull · in 3 recurrence links

    Response · 1 stated action
    2018-0388-Responses.pdf ↗
    “The Head of:Healthcare.at HMP Birmingham will remind all clinical staff (including those working within BCHT) that when reviewing a patient's records for previous medical conditions that the following most be followed: ; ; "4. The clinician will check the 'summary and family history' section of System 2. The clinician will check the 'quick glance' section of System1 3, The clinician will use the 'search function' to check for the medical conditions » relevant to the. clinical intervention they”
  • Bradley Brown30 Nov 2018

    Coroner Lisa Hashmi · Manchester (North) · in 1 recurrence link

    Response · 1 stated action
    2018-0374-Response-by-HM-Prison-and-Probation-Service.pdf ↗
    “the Governor at HMP Buckley Hall has instructed all Governors at the establishment that they should not enter into local agreements to accept transferred prisoners on a Friday. This will be reviewed once the changes to the provision of healthcare have been embedded.”
  • Thomas Nicol30 Nov 2018

    Coroner Geoffrey Sullivan · Hertfordshire · in 1 recurrence link

    Response · 1 stated action
    2018-0375-Response-by-Department-of-Health-Social-Care.pdf ↗
    “NHS England is also reviewing the current prison transfer and remission guidance, published by the Department of Health and Social Care in 20113. In particular, the review is looking at whether the timescales within the guidance take into account clinical urgency and need. The revised guidance will be subject to full, public consultation in due course.”
    Response · 1 stated action
    2018-0375-Response-by-NHS-England.pdf ↗
    “Since 2016, NHS England and respective stakeholders have been engaged in various multi-faceted programmes of work with the specific intention of improving the mental health pathway and is focused on ensuring timely referral, assessment and access to high quality care, and similarly ensuring that remission back to prison also takes place without delay to enable good throughput.”
  • Daniel Stokes5 Nov 2018

    Coroner Neil Cameron · South Yorkshire (East)

    No published response from this organisation found.

  • Elizabeth Self29 Oct 2018

    Coroner Christopher Dorries · South Yorkshire (West)

    No published response from this organisation found.

  • Timothy Mason26 Oct 2018

    Coroner Roger Hatch · Kent (North-West)

    Response · 1 stated action
    2018-0351-Response-by-NHS-England-1.pdf ↗
    “the practice has now switched on the necessary alerts prompting the offer for patients who have not received the Men ACWY vaccination.”
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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error