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recurance

NHS England

548
reports received
153
with a published response found
69
recurrence chains
199
reports in those chains
  • Coroner Fiona Wilcox · London Inner (West)

    No published response from this organisation found.

  • Jennifer Lacey24 Oct 2018

    Coroner Fiona Wilcox · London Inner (West)

    No published response from this organisation found.

  • Tom Cribley9 Oct 2018

    Coroner Julie Goulding · Liverpool and Wirral · in 3 recurrence links

    No published response from this organisation found.

  • Stephen Jackson4 Oct 2018

    Coroner Emma Brown · Birmingham and Solihull

    No published response from this organisation found.

  • Michael Cooper4 Oct 2018

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

    Response · 1 stated action
    NHS-England-Response.pdf ↗
    “the CCG will lead the establishment of an oversight group which involved all stakeholders . The oversight group will work on the delivery of actions from this meeting and will meet on a monthly basis.”
    Response · 1 stated action
    Birmingham-and-Solihull-CCG-Response.pdf ↗
    “The CCG has taken the opportunity, as part of this investigation, to review its broader quality assurance processes and identify any learning outside the scope of the Regulation 28 reports.”
  • Bradley Morgan4 Oct 2018

    Coroner Emma Brown · Birmingham and Solihull

    No published response from this organisation found.

  • Simon Graham4 Oct 2018

    Coroner Emma Brown · Birmingham and Solihull

    No published response from this organisation found.

  • William Edge4 Oct 2018

    Coroner Emma Brown · Birmingham and Solihull · in 2 recurrence links

    Response · 6 stated actions
    NHS-England-Response.pdf ↗
    “Undertakes a monthly contract review of its providers. Since February 2018, following an 'inadequate' rating by the Care Quality Commission of FTB, the CCG has led the development of a Quality Improvement Board to oversee and provide assurance on a CQC improvement Action Plan and a System Improvement Plan.”
    “Proactively manages demand with a series of initiatives to reduce unnecessary admissions and avoid delayed transfers of care, such that capacity can be optimally managed.”
    “Funding: In 2017/18 provided additional investment in mental health services above the contract value amounting to £4,611,000 for BSMHFT (3.7% increase) and £6,235,000 for FTB (22.6% increase).In 2018/19 the CCG provided additional investment in BSMHFT amounting to £3,117,000 (2.4% increase) and FTB amounting to £2,881,000 (9.3% increase). Further”
    “Undertakes mortality and incident review seriously and in line with national policy. The coroners' letters have prompted a comprehensive review of mortality and incident governance which will result in improved care quality and learning from incidents.”
    “Oversight of strategic and operational issues: the CCG will lead the establishment of an oversight group which involved all stakeholders . The oversight group will work on the delivery of actions from this meeting and will meet on a monthly basis.”
    “Risk assessment: this needs to be available and of high quality 24 hours a day, 7 days a week. We will ensure services are commissioned and provided to ensure this occurs in order to provide safe and effective care.”
    Response · 1 stated action
    Birmingham-and-Solihull-CCG-Response.pdf ↗
    “The CCG is committed to establishing and maintaining a mental health system which facilitates timely access to inpatient care for those who need it, whilst ensuring that community-based provision is adequately resourced to support recovery in the most appropriate environment.”
  • Michael Wheeler4 Oct 2018

    Coroner Emma Brown · Birmingham and Solihull

    No published response from this organisation found.

  • Coroner Fiona Wilcox · London Inner West

    No published response from this organisation found.

  • Karl Willis24 Aug 2018

    Coroner Lydia Brown · Exeter and Greater Devon · in 2 recurrence links

    Response · 1 stated action
    2018-0256-Response-by-NHS-England.pdf ↗
    “We have responsibility for ensuring that GPs work within the terms of their contract and pharmacies adhere to their Terms of Service which are outlined in the NHS (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013). The Board can take action such as issuing breach notices and requiring action or withholding payments in certain circumstances.”
  • Sheila Ridgway16 Jul 2018

    Coroner Rashid Sohall · Manchester (City) · in 1 recurrence link

    No published response from this organisation found.

  • Lindsey Tyrrell29 Jun 2018

    Coroner Anthony Mazzag · Manchester (City)

    No published response from this organisation found.

  • Lauren Sandell25 Jun 2018

    Coroner Nadia Persaud · London (East)

    No published response from this organisation found.

  • Marjorie McMahon25 Jun 2018

    Coroner Rachel Galloway · Manchester (South)

    No published response from this organisation found.

  • Sneh Chaudhry15 Jun 2018

    Coroner Sean Cummings · London (West)

    No published response from this organisation found.

  • Brian Bicat29 May 2018

    Coroner Martin Fleming · West Yorkshire (West) · in 1 recurrence link

    Response · 1 stated action
    2018-0277-Response-by-MHRA.pdf ↗
    “Consider more prominent labels and alerts re fire hazard on product containers”
  • Coroner Alison Mutch · Manchester (South)

    No published response from this organisation found.

  • Graeme Mathieson18 May 2018

    Coroner Andrew Cox · Plymouth Torbay and South Devon

    No published response from this organisation found.

  • Novia Delima20 Apr 2018

    Coroner Alison Mutch · Manchester (South) · in 2 recurrence links

    No published response from this organisation found.

  • Ross Reeves29 Mar 2018

    Coroner Veronica Hamilton-Deeley · Brighton and Hove · in 1 recurrence link

    No published response from this organisation found.

  • Thomas Curtin14 Mar 2018

    Coroner Emma Carlyon · Cornwall and the Isles of Scilly

    No published response from this organisation found.

  • Venkata Kagga7 Mar 2018

    Coroner Alison Mutch · Manchester (South) · in 1 recurrence link

    No published response from this organisation found.

  • Coroner Sarah Bourke · London Inner (North)

    Response · 1 stated action
    2018-0074-Response-by-NHS-England.pdf ↗
    “The North East London NAAASP began in April 2013. At this time Mr [name redacted] was 81 years and would therefore not have received an invitation to have AAA screening. However he would have received screening had he asked for an appointment.”
  • Pauline Pryor12 Jan 2018

    Coroner Emma Carlyon · Cornwall and the Isles of Scilly

    No published response from this organisation found.

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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