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)
“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.”
Central and North West London NHS Foundation Trust
Ronald Meikle24 Mar 2026 · Coroner Sean Cummings · Milton Keynes
First raised 19 Feb 2014 in Simon McAndrew. Hazard: Inadequate information sharing between healthcare providers
Simon McAndrew (2014)
“There are issues of poor communication which need to be addressed.”
This report (2026)
“relevant risk information was spread across multiple recording systems and was not always shared effectively between operational staff and clinical teams.”
First raised 18 Jul 2025 in Patryk Gladysz: Prevention of Future Deaths Report. Hazard: Inadequate mental health team attendance at ACCT reviews
Patryk Gladysz: Prevention of Future Deaths Report (2025)
“Staffing within the Mental Health In-reach team impacting the timely undertaking of meaningful and quality mental health assessments.”
First raised 11 Sept 2017 in Henry Prow. Hazard: Drivers failing to self-report medical conditions to DVLA
Henry Prow (2017)
“criteria required by the DVLA and Department of Transport for the issuing and surrendering of driving licences and the terms and conditions for ensuring appropriate modification of driver's vehicles”
First raised 4 Nov 2021 in Christian Hinkley: Prevention of future deaths report. Hazard: Absence of in-cell automatic fire detection
Christian Hinkley: Prevention of future deaths report (2021)
“Every prison wing is already fitted with an automatic fire detection system for spaces other than for cells.”
Department of Health and Social Care
Albert Bellingham12 Mar 2026 · Coroner Andrew Walker · North London
First raised 10 Jul 2015 in Dorothy McDermott. Hazard: Untrained staff unable to manage pressure sores
Dorothy McDermott (2015)
“Care staff at the home were not trained in either the examination for or care of pressure sores.”
This report (2026)
“Consideration of guidance to support interventionalist, supervisory role with appropriate training for doctors working in care homes when dealing with pressure sore.”
12 Mar 2026 · Coroner Gareth Jones · West Sussex, Brighton and Hove
First raised 25 Sept 2018 in Caitlin Huddleston and Skye Mitchell: Prevention of Future Deaths Report. Hazard: Young drivers carrying peer passengers increase collision risk
Caitlin Huddleston and Skye Mitchell: Prevention of Future Deaths Report (2018)
“(1) That [the deceased] was a driver with only 4 months driving experience after passing her driving test;”
First raised 7 Mar 2024 in Nicola Rayner: Prevention of future deaths report. Hazard: Insufficient inpatient bed capacity leading to delayed discharges and patient harm
Nicola Rayner: Prevention of future deaths report (2024)
“Had an informal Mental Health bed been available on the 6th June 2023, and [the deceased] had been admitted as both she and her psychiatrist had wished, her death would not have occurred.”
Central London Community Healthcare NHS Trust
Asher Blackman6 Mar 2026 · Coroner Andrew Walker · North London
First raised 21 Feb 2020 in Anita Loi. Hazard: Missing documentation and follow up in district nursing
Anita Loi (2020)
“On 11 December 2019 the GP invited the District Nurses Team and Tissue Viability Nurses Team to attend a meeting at the surgery with the practice clinicians to review unexpected deaths and to discuss this case.”
This report (2026)
First raised 13 Oct 2014 in Arsema Dawit. Hazard: Gap in classification and remit leading to insufficient investigation
Arsema Dawit (2014)
“According to the MPS Standard Operating Procedures at the time, the offence could not have been reported as domestic violence as those involved were not adult and was outside the remit of the child abuse investigation team.”
This report (2026)
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)
“3. 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 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)
“My concern here Is that handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”
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)
“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.”
Royal College of Paediatrics and Child Health
Viviana-Ray Butnaru4 Mar 2026 · Coroner Jyoti Gill · Essex
First raised 16 Aug 2024 in Daniel Klosi: Prevention of Future Deaths Report. Hazard: Delayed or missing clinical observations in pediatric emergency care
Daniel Klosi: Prevention of Future Deaths Report (2024)
“It was difficult for the nursing staff to obtain [the deceased]'s observations because he was so distressed. That was understandable, but because of the long wait in a busy department, it meant that on the fourth attendance [the deceased] did not have a full set of observations for over four hours”
East Suffolk and North Essex NHS Foundation Trust
David Fenn27 Feb 2026 · Coroner Lincoln Brookes · Essex
First raised 28 Sept 2020 in June Parlour. Hazard: Junior staff reluctance to challenge senior clinicians
June Parlour (2020)
“The nurse did not feel confident enough to challenge the prescription (as she perceived it) effectively or escalate / refer to another doctor.”
This report (2026)
“The junior doctor did not feel able to challenge the view of the Consultant to discharge nor did they seek to reapproach them with fuller information.”
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.”
No published response from this organisation was found for the earlier report.
Matthew Russell (2016)
“Ensuring that all staff with responsibility for patients in prison have received adequate foundation training and on-‐‐going training in the ACCT procedure.”
This report (2026)
“The concern is not that ACCT documentation disclosed a missed risk factor, but that the available materials show Mr [name redacted] was not subject to ACCT proceedings, despite evidence shortly before death of self-isolation, debt-related vulnerability, known substance misuse and reduced engagement.”
This report (2026)
“There is a policy requirement / expectation that a member of the healthcare team should attend all ACCT reviews.”
What was promised after the earlier report
“Staffing within the Mental Health In-reach team”
This report (2026)
“the expectation that drivers would self-report their conditions (which arises as a matter of legislation) was not being followed”
Sheila Edwards: Prevention of Future Deaths Report (2025)
“there is a substantial risk that neither of the conditions will be reported to the DVLA for monitoring.”
This report (2026)
“the expectation that drivers would self-report their conditions (which arises as a matter of legislation) was not being followed.”
What was promised after the earlier report
“The DVLA will continue to work closely with the panel to explore possible options for change to the existing self-declaration system.”
Rosemary MacAndrew: Prevention of Future Deaths Report (2025)
“The current system for vehicle licensing relies largely upon the self-awareness of a driver and their willingness and\or ability to self-report medical conditions to the DVLA.”
This report (2026)
“the expectation that drivers would self-report their conditions (which arises as a matter of legislation) was not being followed.”
What was promised after the earlier report
“Department will continue to engage with healthcare professionals and their regulatory bodies to understand if there may be circumstances where doctors and health care professionals could be encouraged or supported in notifying the DVLA when appropriate”
This report (2026)
“The Ministry of Justice has determined that in-cell automatic fire detection (AFD) is necessary to minimise the risk of harm from fires.”
What was promised after the earlier report
“The rollout of the automatic fire safety systems nationally relies on a sustained level of investment and on the availability of resources to ensure that there is minimal disruption to the prison regimes. Fire safety systems are costly and complex to install and there can be delays in these works due to important measures to maintain the safety of staff and prison residents and also to maintain the overall security of the prison. It can therefore take a number of years to install the full system”
No published response from this organisation was found for the earlier report.
This report (2026)
“The driver of the vehicle which crashed was 17 years of age. The three passengers in the car including [the deceased] who died were also under 18.”
What was promised after the earlier report
“the Department has decided to use the introduction of GDL in Northern Ireland as a pilot, to gather evidence on the potential for GDL in Great Britain.”
Charlie Hopkins and William Robinson: Prevention of future deaths report (2024)
“As set out above, the court found that it was possible that the fact that [the deceased] had only just passed his driving test contributed to the collision.”
This report (2026)
“I am concerned that when 17 year olds pass a driving test, they can drive on any road in the UK including motorways without any adult supervision.”
What was promised after the earlier report
“We will be considering policies relating to young, new drivers during this development.”
Joseph Walsh: Prevention of Future Deaths Report (2025)
“Currently there are no legal restrictions upon the licences of young and /or newly qualified drivers and the current vehicle licensing regime permits the carrying of young persons as passengers”
This report (2026)
“I am concerned that when 17 year olds pass a driving test, they can drive on any road in the UK including motorways without any adult supervision.”
This report (2026)
“There is a long standing and well publicised concern that there are fewer mental health beds than patients who are assessed as needing these. I draw your attention to the fact that this situation is ongoing and continues to pose a risk to life.”
No published response from this organisation was found for the earlier report.
Jagjeet Singh: Prevention of Future Deaths Report (2024)
“I heard that a bed on the mental health ward should have been available for Mr [name redacted] when he was discharged from the medical wards but that there is a chronic shortage of mental health beds and not just in London but nationally.”
This report (2026)
“There is a long standing and well publicised concern that there are fewer mental health beds than patients who are assessed as needing these.”
What was promised after the earlier report
“The number of mental health beds required to support a local population is dependent on both local mental health need and the effectiveness of the whole local mental health system in providing timely access to care and supporting people to stay well in the community, therefore reducing the likelihood of an admission being necessary.”
“the initial assessment for Mr [name redacted] by the District Nurses did not record his next of kin details or what to do should the district nurse not be able to gain access.”
What was promised after the earlier report
“We have updated our Triaging Standard Operating Procedures to ensure a robust process for the management and response to referrals.”
“That there may have been missed opportunities for the IOPC and Metropolitan Police Service from their investigations to identify that [the deceased] was a victim of domestic abuse and coercive control, which would have enabled her to be protected.”
Alexander Davidson (2019)
“The NHS 111 telephone triage service uses the NHS Pathways computer system to triage patients via pre-determined question/answer based algorithms. The pre-determined questions are the same whether the caller is an adult or a child.”
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.”
Jade Griffiths-Jones: Prevention of future deaths report (2024)
“if hospital handover delays didn't exist they would be likely to be meeting their response targets as they did before hospital delays became chronic”
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, reducing emergency response capacity during periods of high demand.”
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.”
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, reducing emergency response capacity during periods of high demand.”
Harry Dunn: Prevention of Future Deaths Report (1) (2024)
“I am concerned that these continuing delays for ambulances at hospital handovers reflects a risk of deaths into the future.”
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 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.”
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,”
What was promised after the earlier report
“maintaining capacity gains in acute hospital beds and ambulance hours on the road achieved in 2023-24”
Nicola Owens: Prevention of Future Deaths Report (2025)
“The delay in an ambulance attending patients due to the unavailability of ambulances. This delay being significantly contributed to by the handover delays in 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.”
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”
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”
Andrew Waters: Prevention of Future Deaths Report (2025)
“Significant handover delays leading to ambulance resources being tied up at hospital”
This report (2026)
“Ambulance handover delays affecting emergency availability”
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 for longer than necessary and then had a knock on impact on the ability of the ambulance service to respond to calls”
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.”
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 and increased mortality risks for patients in the community waiting for emergency ambulances.”
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
“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.”
What was promised after the earlier report
“We will be meeting with NEAS in September 2015 to discuss and monitor how they are managing their delivery of the service, what is their current position of staffing levels and identified vacant posts and their current recruitment position.”
This report (2026)
“Incomplete documentation to be addressed to include all updates from nursing staff in relation to observations and escalations; and handovers from the medical team to one another to be clearly recorded.”
What was promised after the earlier report
“The Trust has ratified and disseminated an updated guideline for recording and escalating physiological observations in children and young people. This includes guidance for staff that the inability to obtain observations should be considered and escalated in the same way as abnormal observations.”
What was promised after the earlier report
“We have reviewed and updated the ESNEFT Morphine Administration Guideline and the Naloxone Administration Guideline in line with those set out in the British National Formulary (BNF).”