First raised 14 Jan 2019 in Dane Pearson. Hazard: Inadequate CAWN risk assessment for young persons
Dane Pearson (2019)
“In issuing, the CAWN there was no evidence that his known vulnerability had been taken into account. A risk assessment had not been carried out.”
This report (2026)
“Thought should be given to the creation of a young person's protection by way of creation of an extension to the CAWN for the young person, against the adult creating that safeguarding risk e.g. young person's abuse warning notice.”
First raised 5 Jan 2022 in Richard Sanders: Prevention of future deaths report. Hazard: Insufficient awareness of immersion pulmonary oedema risk for high bloodpressure
Richard Sanders: Prevention of future deaths report (2022)
“Whether there is sufficient awareness of the risks & affects of immersion pulmonary oedema by those engaged &/ or participating in the activity of diving.”
First raised 20 Feb 2019 in Kevin Miles. Hazard: Divers not disclosing health problems during HSE medicals
Kevin Miles (2019)
“There is currently no re uirement to obtain the diver's General Practitioner records which are often a 'hub' of various information regarding treatment by both hospital and/or private clinic)”
This report (2026)
First raised 25 Feb 2014 in Arthur Brockett-Deakins. Hazard: Maternal heart rate misinterpreted as fetal heart rate
Arthur Brockett-Deakins (2014)
“The inquest heard that new CTG machines incorporate maternal ECG or pulse oximetry, which alerts staff to investigate when MHR and FHR appear the same.”
This report (2026)
“It is a matter of concern that the Home Delivery kit does not include a pulse oximeter for maternal heart rate.”
29 Apr 2026 · Coroner Nicholas Rheinberg · Wiltshire and Swindon
First raised 12 Aug 2025 in Chloe Barber: Prevention of Future Deaths Report. Hazard: Lack of defined transition pathway between CAMHS and adult services
Chloe Barber: Prevention of Future Deaths Report (2025)
“there is not necessarily any clearly defined pathway that assists young persons making the transition between Childhood and Adolescent Mental Health Service (CAMHS) and adult psychiatric services, to ensure a smooth transit and continuity of care.”
First raised 31 Jul 2019 in Nigel Abbott. Hazard: Misunderstanding of section 135 mental health act powers
Nigel Abbott (2019)
“there is a misunderstanding between the agencies as to how section 135 Mental Health Act 1983 can work in an urgent situation”
This report (2026)
First raised 18 Feb 2025 in Zahra Mohamed: Prevention of Future Deaths Report. Hazard: Delay in obtaining and executing s135 warrants
Zahra Mohamed: Prevention of Future Deaths Report (2025)
“if an application had been submitted to the magistrates' court that day, it is unlikely that the warrant would have been executed before Mrs [name redacted] death. In evidence, I was informed by a number of mental health professionals that the time taken for a s135(2) warrant to be obtained from the magistrates' court and executed by the police was in the region of 2 weeks.”
First raised 26 Apr 2022 in Ashleigh Timms: Prevention of future deaths report. Hazard: Inadequate staff training for fire evacuation in specialist housing
Ashleigh Timms: Prevention of future deaths report (2022)
“The operator of the premises failed to ensure that staff on duty were competent to carry out a fire evacuation”
This report (2026)
Nottinghamshire Healthcare NHS Foundation Trust
Jonathan Thornton8 Apr 2026 · Coroner Alexandra Pountney · Nottingham and Nottinghamshire
First raised 12 Oct 2016 in Rohid Shergill. Hazard: Inadequate information sharing between healthcare teams
Rohid Shergill (2016)
“Information‐sharing between the two trusts - by way of shared IT and / or the use of shared care folders kept in the family home - with clear training to staff on what information should be recorded there.”
8 Apr 2026 · Coroner Alexandra Pountney · Nottingham and Nottinghamshire
First raised 25 Oct 2016 in Richard Walsh. Hazard: Lack of communication between prison healthcare and operational staff
Richard Walsh (2016)
“There appeared to be not only serious failures of communication, but failures from inadequate processes of communication between custodial and health professionals, between police, court, health care and prison services”
First raised 16 May 2025 in Patricia Bushell: Prevention of Future Deaths Report. Hazard: Inadequate temporary signage at junction
Patricia Bushell: Prevention of Future Deaths Report (2025)
“I am however concerned that in respect of the national regulations, I am told that the temporary signage installed at the collision site was compliant with the guidance.”
First raised 15 Nov 2023 in Lynda Blackmore: Prevention of future deaths report. Hazard: Delayed ambulance handover at hospitals
Lynda Blackmore: Prevention of future deaths report (2023)
“handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital”
This report (2026)
First raised 21 May 2015 in Barbara Patterson. Hazard: Ambulance handover delays at hospitals reduce availability
Barbara Patterson (2015)
“During the inquest evidence was given that ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff.”
This report (2026)
“Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”
First raised 26 May 2016 in Peter Scott. Hazard: Ambulance crew availability reduced by hospital handover delays
Peter Scott (2016)
“Finally, I was made aware that one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals.”
This report (2026)
“Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”
First raised 26 May 2016 in Ian Brown. Hazard: Inadequate ACCT case management at HMP Woodhill
Ian Brown (2016)
“(1)During the course of the evidence | was referred to the most recent report from the HM Inspector of Prisons that highlighted "Recommendations made by the Prisons and Probation Ombudsman following previous deaths in custody, such as the need to improve the quality of ACCT case management documentation for prisoners at risk of suicide or self harm, had not been implemented with sufficient rigour.”
This report (2026)
“I am concerned about the level of training and awareness around the risks of immersion pulmonary oedema('IPO') for divers with high blood pressure.”
“I am concerned that there is currently no requirement for doctors conducting HSE medicals to confirm that they have advised patients who fail the HSE medical, for reasons similar to those in [the deceased]'s case, of the risks of IPO.”
No published response from this organisation was found for the earlier report.
This report (2026)
“commissioning mental health provision for children and adolescents with a strict cut off date of the individual's 18th birthday could be prejudicial to mental health in certain circumstances.”
“A lack of awareness by the two less experienced officers about the process under section 135 MHA 1980, and a lack of inquiry by the more experienced officer as to the existence of such a warrant”
This report (2026)
“A lack of awareness by the two less experienced officers about the process under section 135 MHA 1980, and a lack of inquiry by the more experienced officer as to the existence of such a warrant, together with a concern that it was not clear from the evidence where information about the warrant could be obtained by officers.”
What was promised after the earlier report
“The MPS will now request a weekly Community Consultation Meeting between AMHPs, MH policing teams, Neighbourhood policing teams, Crisis Teams, and Home Treatment Teams (HTT) to discuss those people who may be reaching the threshold for an assessment/S135 warrant application.”
“Staff training is not standardised for ECSA (or sheltered accommodation more generally) and may not include, for example, evacuation strategy, emergency evacuation plans, the use of telecare/fire alarm system and fire suppression systems”
What was promised after the earlier report
“Face to face fire safety training is now provided to staff. This training is provided annually by Pinnacle and is delivered at each premises. The training covers, amongst other things, evacuation routes and procedures, fire drills and fire safety measures. A copy of the training handbook provided to staff as part of that training is attached.”
This report (2026)
“I am concerned that the lack of formal information sharing between the two departments gives rise to a risk of future death.”
No published response from this organisation was found for the earlier report.
This report (2026)
“I am concerned that the lack of formal information sharing between the two departments gives rise to a risk of future death. Information sharing between Prison Healthcare and Operational Prison Staff.”
This report (2026)
“I am concerned of that the only recourse for a Network Inspector to get temporary traffic management signage replaced, is an apparently protracted procedural route involving multiple individuals remote from the site”
No published response from this organisation was found for the earlier report.
“Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available”
John Seagrove, Pauline Humphris and Patricia Steggles: Prevention of future deaths report (2023)
“What is of concern, however, is that these gains have not been maintained and the situation has now worsened with 15-20 ambulances waiting outside the ED on occasions over the last three weeks.”
This report (2026)
“Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought”
Harry Dunn: Prevention of Future Deaths Report (1) (2024)
“The Inquest heard that EMAS was unable to meet mean response standards at the time of the 999 call.”
This report (2026)
“Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought,”
What was promised after the earlier report
“the Health Secretary has ordered a full and independent investigation into NHS performance to provide a frank assessment of the issues and challenges it faces”
Kevin Woods: Prevention of Future Deaths Report (2024)
“Continuing average handover delays (and therefore response delays) which create a risk of future deaths. The averages conceal spikes of delayed handover and ambulance response times which increase the risk of mortality.”
This report (2026)
“Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”
What was promised after the earlier report
“developing local partnership working between the NHS and social care and making sure people get the right support from health and social care services to return home as soon as possible”
Lachlan Campbell (2): Prevention of Future Deaths Report (2025)
“Delay in ambulance response attributable to delays in handover of patients at Royal Cornwall Hospital”
This report (2026)
“Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought”
Andrew Waters: Prevention of Future Deaths Report (2025)
“Significant handover delays leading to ambulance resources being tied up at hospital with increased risk in mortality for patients in the community waiting for emergency ambulances.”
This report (2026)
“Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”
What was promised after the earlier report
“The NHS planning guidance also includes an implementation target for improving A&E waiting times compared to 2024/25, with a minimum of 78% of patients seen within 4 hours in March 2026 and increasing the proportion of patients admitted, discharged, and transferred from an emergency department within 12 hours across 2025/26 compared to 2024/25.”
Bernard Lyon: Prevention of Future Deaths Report (2025)
“significant delays in the handover from the ambulance to the ED team. This was due to pressure on the ED but meant that ambulances were tied up”
This report (2026)
“Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available”
James Smith: Prevention of Future Deaths Report (2025)
“Significant handover delays at RCHT and other southwest hospitals leading to ambulance resources being tied up with increased response delays”
This report (2026)
“Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought”
What was promised after the earlier report
“On 6 June 2025, we published our Urgent and Emergency Care Plan for 2025/26. The plan requires the NHS to focus on those activities that will have the biggest impact on improving urgent and emergency care performance, including ambulance response and handover times: - at least 78% of patients in A&E departments will be seen within 4 hours.”
Alexander Davidson (2019)
“The pre-determined questions are the same whether the caller is an adult or a child. [name redacted] struggled to comprehend some of the medical terminology used during these calls.”
This report (2026)
“Evidence showed that a key NHS Pathways question used during triage was not understood by the caller and did not elicit clinically significant information.”
What was promised after the earlier report
“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.”
Dennis King: Prevention of future deaths report (2024)
“Availability of ambulances to carry out transfers in a timely manner, in urgent cases, between NHS Hospitals and in responding to 999 and 111 calls in the community.”
This report (2026)
“Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought”
Jade Griffiths-Jones: Prevention of future deaths report (2024)
“availability of ambulance crews is continuing to be compromised by delays at hospitals resulting in delays in response times which creates a risk to the life.”
This report (2026)
“Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”
What was promised after the earlier report
“The plan outlined key actions to recover and improve urgent and emergency care services, including: - improving ambulance response times; - increasing ambulance capacity through growing the workforce (for example, increasing clinical capacity in control rooms); - alongside broader system actions to improve flow through hospitals and reducing handover delays; - speeding up discharges from hospitals; - expanding new services in the community.”
Colin Wiles: Prevention of Future Deaths Report (2024)
“The waiting times for ambulances to hand over patients at Hull Royal Infirmary were excessive that day leading to 160 hours of lost ambulance time.”
This report (2026)
“Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought”
Nicola Owens: Prevention of Future Deaths Report (2025)
“This delay being significantly contributed to by the handover delays in hospitals.”
This report (2026)
“Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”
What was promised after the earlier report
“The NHS will focus on delivering the following range of practical actions to improve performance in 2025/26: - working towards delivering hospital handovers within 15 minutes, and implementing joint working arrangements that ensure that no handover takes longer than 45 minutes, - improving ambulance 'hear and treat' service rates, including increasing the proportion of Category 2 ambulance incidents where an ambulance clinician provides advice and treatment over the phone, - ensuring all 999 am”
This report (2026)
“Concern 11: Repeated systemic concerns at HMP Woodhill Material before the court from oversight and inspection bodies demonstrated that concerns about drugs, safety, violence, self-isolation, observation panel compliance, ACCT weaknesses and welfare monitoring at HMP Woodhill had been identified over time.”
What was promised after the earlier report
“The prison is also implementing a system to provide each offender supported through the ACCT process with a designated case manager throughout the period for which the ACCT remains open.”