Skip to content
recurance
3
reports received
3
with a published response found
0
recurrence chains
0
reports in those chains
  • Jason Pendlebury12 Mar 2020

    Coroner Matthew Cox · Manchester North

    Response · 1 stated action
    2020-0069-Response-from-North-West-Ambulance-Service_Redacted-1.pdf ↗
    “The Trust should be grateful if you would allow us to provide an update following that meeting and within six months of the date of this letter to report the work that has been undertaken to better meet the needs of individuals such as Mr [name redacted] and those in mental health crisis in the community.”
  • Coroner Joanne Kearsley · Manchester (North)

    Response · 1 stated action
    2018-0411-Response-by-GMCA.pdf ↗
    “We identified eight issues which required attention, and specified that relevant task and finish groups would be convened to address them. These eight themes were: - A common understanding of the duties, powers and training of staff in the respective agencies in their response to demands for service from people with mental ill-health. - Improved information sharing processes through the development of the multi-agency 'Mental Health Control Room Triage' pilot service, jointly funded by NHS”
  • David Lee28 Jun 2017

    Coroner Julie Robertson · Manchester (North)

    Response · 1 stated action
    2017-0432.pdf ↗
    “the Trust have revised the relevant guidance in respect of incidents where call takers should remain on the line and have circulated this to all EOC Supervisors, with the following key points emphasized as direct learning from this case: e First party callers who are not alert cannot be disconnected after 10 minutes. The call takers should remain on the line.”
  • Built with
  • NVIDIA Nemotron Nano, Super and Ultra
  • Nebius Token Factory inference
  • Qwen3 Embedding 8B on Token Factory
  • Tavily follow-up web search
  • Postgres and pgvector search
  • Next.js site

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