First raised 1 May 2024 in Jordan Howarth: Prevention of future deaths report. Hazard: Antibiotic prescribing without joint discussion or swallow assessment
Jordan Howarth: Prevention of future deaths report (2024)
“there was not a joint approach to his care and no detailed discussions regarding the decision to withhold antibiotics”
This report (2026)
“prescription of oral antibiotics without conducting a swallow assessment in a patient presenting with swallowing difficulties and lockjaw”
Department of Health and Social Care
Malcolm Campbell17 Jun 2026 · Coroner James Thompson · Gateshead & South Tyneside
First raised 21 Jul 2017 in Pauline Taylor. Hazard: Lack of verbal warning and fire risk flag for paraffin emollient creams
Pauline Taylor (2017)
“(4) Members of the public are able to purchase emollient creams across the counter but are not verbally made aware of the potential fire hazards of emollient cream containing a low level of paraffin.”
First raised 18 Jan 2017 in Teresa Dennett. Hazard: Delayed referral for neurosurgical care
Teresa Dennett (2017)
“absence of a clear pathway for referral for life-saving neurosurgery”
This report (2026)
“neurosurgery is not a specified Pathways category, nor is it part of the”
8 Jun 2026 · Coroner Lindsey Tonks · Staffordshire and Stoke on Trent
First raised 26 Oct 2015 in Neil Garry. Hazard: Missing pedestrian crossing on busy ring road
Neil Garry (2015)
“There is no pedestrian crossing at, or in the vicinity of, Ramshead Approach in Leeds. The Ring Road (A6120) is a busy road in that particular area and is frequently”
This report (2026)
“There are no pedestrian guardrails either side of the carriageway at what appears to be a primary location used by people for their speed and convenience, to avoid the need to walk further to use the pedestrian crossings”
8 Jun 2026 · Coroner Lindsey Tonks · Staffordshire and Stoke on Trent
First raised 10 Mar 2016 in Derek Nixon. Hazard: Missing guardrails at primary crossing point
Derek Nixon (2016)
“heard police evidence that many pedestrians, by far the majority, when walking down Fountain Street then walked across Ball Haye Street at the 'Keep Clear' point because there was nothing to prevent them.”
This report (2026)
Essex Partnership University NHS Foundation Trust
Katharine Corrigan1 Jun 2026 · Coroner Sonia Hayes · Essex
First raised 25 Jul 2024 in Danny Anderson: Prevention of Future Deaths Report. Hazard: Inadequate risk assessment documentation and inaccurate record keeping
Danny Anderson: Prevention of Future Deaths Report (2024)
“There was no evidence of any adequate formulation of risk prior to [the deceased]'s discharge from hospital on the 14 December 2022 and no evidence of any adequate risk formulation prior to [the deceased]'s discharge from the community mental health team in January 2023.”
First raised 14 Oct 2024 in Mia Gauci-Lamport: Prevention of Future Deaths Report. Hazard: Inadequate medical documentation oversight
Mia Gauci-Lamport: Prevention of Future Deaths Report (2024)
“[the deceased]'s medical records at TCT were neither comprehensive nor easy to understand and did not conform to the expected standard”
First raised 13 Dec 2024 in Laura-Jane Seaman: Prevention of Future Deaths Report. Hazard: Inadequate medical documentation in acute trust
Laura-Jane Seaman: Prevention of Future Deaths Report (2024)
“Significant omissions in the medical record-keeping and some medications administered were entered into a medication chart from a previous admission in November 2023”
First raised 19 Jun 2024 in Aaron Deeley: Prevention of future deaths report. Hazard: Untrained staff conducting mental health assessments
Aaron Deeley: Prevention of future deaths report (2024)
“The acute care healthcare professionals do not have specialist mental health training to conduct a mental health assessment and the consequential presenting harm.”
26 May 2026 · Coroner Gareth Jones · West Sussex, Brighton and Hove
First raised 31 Jan 2014 in Ryan Chapman. Hazard: Staff unaware of leave policy requirements
Ryan Chapman (2014)
“During the course of the evidence it was shown that there a lack of understanding by staff of the Trust's Leave for Non detained patients Policy.”
Department of Health and Social Care
David Smart22 May 2026 · Coroner Joanne Andrews · West Sussex, Brighton and Hove
First raised 19 Jul 2023 in Thelma Radmore: Prevention of future deaths report. Hazard: Ambulance crew waiting in corridor due to insufficient clinical space
Thelma Radmore: Prevention of future deaths report (2023)
“The wait Mrs [name redacted] experienced with the ambulance crew in the corridor was due to demand for space within the Emergency Department due to patient numbers and issues with patient flow due to challenges in discharging patients from wards”
First raised 15 Oct 2024 in Tamara Davis: Prevention of Future Deaths Report. Hazard: Patients treated in ED corridor due to lack of clinical space
Tamara Davis: Prevention of Future Deaths Report (2024)
“when the Emergency Department of the Royal Sussex County Hospital, Brighton reached capacity patients would be moved to and treated in the corridor as there was no clinical area available to do so”
His Majesty's Prison and Probation Service
George Haldenby21 May 2026 · Coroner Rachael Griffin · Dorset
First raised 25 Mar 2015 in Keith Murphy. Hazard: Lack of basic first aid training and CPR among prison officers
Keith Murphy (2015)
“Action is required to ensure that Prison Officers and Staff with direct access to prisoners have basic first aid training, CPR training and familiarisation with the use of a defibrillator.”
First raised 18 Jul 2025 in Patryk Gladysz: Prevention of Future Deaths Report. Hazard: Lack of regular first aid training among custodial staff
Patryk Gladysz: Prevention of Future Deaths Report (2025)
“First Aid refresher training is not up to date for all healthcare staff.”
This report (2026)
“After prison officers and prison staff carry out their induction training which covers basic first aid training including the delivery of cardio pulmonary resuscitation (CPR), there is no further mandatory refresher training on first aid or CPR.”
First raised 18 May 2016 in Ratidzai Sangare. Hazard: Delayed resuscitation due to insufficient staff awareness or training
Ratidzai Sangare (2016)
“Healthcare staff were unaware or did not recognise that Mrs [name redacted] condition required immediate cardiopulmonary resuscitation, the activation of the alarm, and the summoning of an ambulance”
This report (2026)
What was promised after the earlier report
“The joint approach to Mr [name redacted] care from both the microbiologist and the consultant physician, specifically around the decision to withhold antibiotics.”
This report (2026)
“Mr [name redacted] was prescribed an emollient cream which carers would apply to his legs. This cream had a paraffin base. A fire investigator opines the cream may have over time soaked into bedding and the carpet near his bed as, well as its presence in its container, once the fire started allowed the fire to spread.”
Maureen Milton (2019)
“Evidence given by fire investigators was that they are increasingly attending fires involving (mostly) the elderly where there is evidence of petrol based emollient cream in use.”
This report (2026)
“However, there was no ability to place on a patient's medical records a 'Fire' flag to show that person has been classed as a fire risk due to smoking in bed etc.”
No published response from this organisation was found for the earlier report.
“There are no pedestrian guardrails either side of the carriageway at what appears to be a primary location used by people for their speed and convenience, to avoid the need to walk further to use the pedestrian crossings”
What was promised after the earlier report
“proposed to install a short section of guardrail around the northern radius of the Fountain Street junction”
This report (2026)
“Ms [name redacted] risk assessment and care plans had not been appropriately updated in her medical records such that: a. They had not been developed in collaboration with her and did not contain: i. Early waring signs and triggers”
What was promised after the earlier report
“The Trust have made improvements, at pace in respect of the processes for formulation of risk on discharge with the implementation of discharge steps developed by the Trust Patient Flow Team. There has also been a change in practice to ensure we hold a discharge planning meeting with the Multi-Disciplinary Team (MDT) before discharge from hospital. Clinical service managers and matrons join discharge meetings to ensure a collaborative approach.”
Darren Turner: Prevention of Future Deaths Report (2025)
“Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to [the deceased]'s risk assessment consistent with Trust policy.”
This report (2026)
“Ms [name redacted] risk assessment and care plans had not been appropriately updated in her medical records such that:”
What was promised after the earlier report
“The Trust has initiated a Record Keeping Safety Improvement Programme (SIP). Part of this includes considering how to address issues of copying and pasting.”
Julie Beasley: Prevention of Future Deaths Report (2025)
“Multiple experienced members of the mental health teams had contact with Mrs [name redacted] between January and March and did not make detailed entries into the medical”
This report (2026)
“Ms [name redacted] risk assessment and care plans had not been appropriately updated in her medical records such that:”
What was promised after the earlier report
“The Trust has continued to review our assessment processes to ensure that the appropriate reviews are undertaken in a timely manner and are supported through the MDT approach which then supports a joined up approach to patient assessments. Staff in the Mental Health Crisis team are required to undertake a mental health assessment for all patients, which is monitored and audited via supervision meetings and compliance reviews.”
Stuart Berry: Prevention of Future Deaths Report (2025)
“(c) Failures in Risk Assessments: specifically, failures to appropriately up- date and document matters relating to Mr [name redacted] risk assessment consistent with Trust policy.”
This report (2026)
“6. Ms [name redacted] risk assessment and care plans had not been appropriately updated in her medical records such that:”
This report (2026)
“There was an absence of appropriate medical records recorded for Ms [name redacted] to understand her clinical presentation”
This report (2026)
“There was an absence of appropriate medical records recorded for Ms [name redacted] to understand her clinical presentation”
What was promised after the earlier report
“All Mid and South Essex Hospital NHS Foundation Trust ('MSE') sites have now adopted an electronic prescribing and medication administration (EPMA) platform. EPMA facilitates team members across specialties to record accurately and contemporaneously in one place. The system allows all registered users to clearly see what other medications have been administered and by whom. Staff details are visible against the record so that each interaction is name and date stamped within the patient record.”
David Bennett: Prevention of Future Deaths Report (2025)
“Evidence was heard that the mental health crisis staff do not appear to have appropriate access to the primary care mental health System One records and there is a risk that vital information is not being shared.”
This report (2026)
“There was an absence of appropriate medical records recorded for Ms [name redacted] to understand her clinical presentation other than very basic information on the INR platform on INR results and medication dose.”
What was promised after the earlier report
“We are in the process of devising a 'Shared Care Record' with colleagues across the Integrated Care Board enabling unified access to patient records. The collaboration includes us, Essex Partnership University Trust (EPUT), Primary Care, Social Care and other key stakeholders set out below.”
This report (2026)
“There were not sufficient trained staff to conduct the enhanced observations required to monitor Abbi with her known risk of severe self-harm whilst she was awaiting assessment under the Mental Health Act and actively attempting to take her own life.”
What was promised after the earlier report
“We have therefore added a new flowchart to our 'Admission & Treatment of Patients with a Mental Health Disorder in an Acute Hospital Setting' Policy. A copy of the flowchart is attached for reference.”
This report (2026)
“I am concerned that s17 leave is being authorised by staff in ignorance of the leave conditions. In this particular case, the responsible clinician granted leave on the 13th of February 2025, a condition being that [the deceased] had to test negative for drug use before leave was allowed.”
No published response from this organisation was found for the earlier report.
Danuta Corbett (2014)
“Leave was considered first on 1.11.2013 when Mrs. [name redacted] was on 15 minute observations.”
This report (2026)
“staff are unaware of leave conditions and this is not being properly monitored.”
What was promised after the earlier report
“We have since reinforced with staff that should these quite extraordinary circumstances arise again then a retrospective note must be completed.”
This report (2026)
“there were around 20 patients in the corridor as the Department had reached capacity and there was no clinical area available to do so”
This report (2026)
“there were around 20 patients in the corridor as the Department had reached capacity and there was no clinical area available to do so”
What was promised after the earlier report
“NHS England is working through the operating model so that NHS England's Regions can support providers to eliminate crowding in Emergency Departments in the longer term.”
Maureen Batchelor: Prevention of Future Deaths Report (2025)
“when the Emergency Department of the Royal Sussex County Hospital, Brighton reached capacity patients would be moved to and treated in the corridor as there was no clinical area available to do so.”
This report (2026)
“there were around 20 patients in the corridor as the Department had reached capacity and there was no clinical area available to do so.”
What was promised after the earlier report
“In June 2025, NHS England published the Urgent and Emergency Care (UEC) Plan for 2025/26, which included an ambition to 'improve flow through hospitals with a particular focus on patients waiting over 12 hours and making progress on eliminating corridor care'.”
This report (2026)
“After prison officers and prison staff carry out their induction training which covers basic first aid training including the delivery of cardio pulmonary resuscitation (CPR), there is no further mandatory refresher training on first aid or CPR.”
Mark Doyle (2017)
“There is no mandatory first aid training for existing (as opposed to new) prison officers.”
This report (2026)
“After prison officers and prison staff carry out their induction training which covers basic first aid training including the delivery of cardio pulmonary resuscitation (CPR), there is no further mandatory refresher training on first aid or CPR.”
What was promised after the earlier report
“Following the inquest I have reflected and reviewed healthcare processes and there have been discussions within the healthcare team. Going forward we will ensure that the Local Operating Procedures (LOPs) are embedded, with senior management undertaking audits, to ensure that where any relevant risks and triggers are identified, we will share information with the prison in the following ways:- - Update on C nomis - entry to be made by allocated healthcare staff - Update the ACCT document and”
Nicola Lawrence (2018)
“Some Prison staff had not received any cardiopulmonary resuscitation training. Either as part of initial training or any refresher training.”
This report (2026)
“After prison officers and prison staff carry out their induction training which covers basic first aid training including the delivery of cardio pulmonary resuscitation (CPR), there is no further mandatory refresher training on first aid or CPR.”
Ryan Trimmer (2019)
“Prison staff are often first responders to medical emergencies of prisoners, but not all have received first aid training.”
This report (2026)
“After prison officers and prison staff carry out their induction training which covers basic first aid training including the delivery of cardio pulmonary resuscitation (CPR), there is no further mandatory refresher training on first aid or CPR.”
Liam Turner: Prevention of future deaths report (2024)
“It is not mandatory for prison officers to have basic first aid training (which includes the provision of CPR) which is in-date. Once a prison officer's three-year period has expired, whilst they may be reminded by the prison establishment that their certification is no longer live, it is not mandatory for them to renew this.”
This report (2026)
“After prison officers and prison staff carry out their induction training which covers basic first aid training including the delivery of cardio pulmonary resuscitation (CPR), there is no further mandatory refresher training on first aid or CPR.”
What was promised after the earlier report
“Following evidence heard at the inquest, you have raised some concerns regarding the first aid training for staff, particularly in relation to the use of CPR. Thank you for bringing your concern to my attention. As you are aware, the HMPPS First Aid Policy Framework was re-issued nationally in August 2023. The revised policy highlights the training requirements for Emergency First Aid and First Aid in prisons, including the importance of Governors ensuring that there is an appropriate number of”
Stephen Sleaford: Prevention of Future Deaths Report (2024)
“Evidence was heard that the majority of those prison officers who had commenced in their roles prior to 2018 had no first aid/basic life-saving skills and no ability/training in undertaking cardiopulmonary resuscitation ('CPR').”
This report (2026)
“After prison officers and prison staff carry out their induction training which covers basic first aid training including the delivery of cardio pulmonary resuscitation (CPR), there is no further mandatory refresher training on first aid or CPR.”
What was promised after the earlier report
“attention. The HMPPS First Aid Policy Framework was re-issued nationally in August 2023. The revised policy highlights the training requirements for Emergency First Aid and First Aid in prisons, including the importance of Governors ensuring that there is an appropriate number of trained staff on duty at all times. To achieve this, a detailed local first aid risk assessment must be produced to determine the number of First Aiders at Work (FAW) and Emergency First Aiders at work (EFAW) required at an”
“After prison officers and prison staff carry out their induction training which covers basic first aid training including the delivery of cardio pulmonary resuscitation (CPR), there is no further mandatory refresher training on first aid or CPR.”
No published response from this organisation was found for the earlier report.