Recent repeats

“There was no signage warning of the dangers of swimming or safety aids at Lock 62 or within the nearby vicinity.”

“Once in the water, there is currently no safety equipment which could assist someone in getting out, whether they are in accidentally or intentionally,”

“Relevant information regarding Mr [name redacted] falls history could not be shared by his Social Worker with other relevant Multi Agencies such as Milford House or the Health Team at the time his Pre Admission Assessment was undertaken as the process/system did not allow it.”

“Training regarding the ACCT process. In previous prison deaths and in response to previous PPO reports, promises have been made about training having been provided to staff”

“(3) When Prison Officers and/or Healthcare staff are given ACCT induction training at HMP Wandsworth, there is no training in the principles of risk formulation”

“No sepsis screening tool was being used by the community health care providers, and so opportunities were lost to consider a diagnosis of sepsis and refer as an emergency for hospital admission and treatment”

“Using a misplaced nasogastric tube is recognised as a 'never event', namely an event which is wholly preventable and should never happen.”

“both key support workers who knew Mr [name redacted] best failed to carry out the 30 minute observations during the morning and afternoon shifts”

“Further at the time of the inquest there were approximately 140 beds at the Queen Elizabeth Hospital occupied by patients who were medically fit to be discharged, but beds could not be found in the community.”

“Although his mental health was clearly deteriorating neither the GP or NEPT referred this case to Essex Police Firearms Department.”

“Firearms Legislation relating to the holding of a shotgun or firearms licence (or both) contains no provision that a person holding a certificate must self report any illness or mental health condition”

“The prison officers did not have even the most basic first aid and cardiopulmonary resuscitation (CPR) training.”

“The Governor of the prison told the court that no refresher CPR training had been provided to prison staff since 2023 notwithstanding the 5 deaths of prisoners by ligature suspension that have occurred since.”

“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.”

“There were no applicable standard operating procedures for worsening patients in the renal unit at the date of [the deceased]'s death and none had been implemented by the date of Inquest.”

“delays in ambulances attending patients in the community are likely to increase the risk of death in Cat 2 instances especially that would otherwise be preventable had the patient been got to hospital in a timely fashion”

“In an acute stroke 'time is brain' which means that the sooner thrombolysis (clot busting drug) is administered the better are the chances of recovery and subsequent survival.”

“The availability, nationally, of Tier 4 beds in paediatric mental health facilities”

“I heard that there are insufficient numbers of Tier 4 Paediatric Mental Health beds available for the children and young people who have been assessed as requiring this level of admission.”

“lack of understanding of how to treat someone with an acute behavioural disturbance”

“in some ambulance localities the required response is allocated Category 2 and in others Category 1. This means that there is not a national standard for response Acute Behavioural Disturbance with active restraint.”