Essex Partnership University NHS Foundation Trust
Stuart Berry1 Dec 2025 · Coroner Sean Horstead · 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.”
This report (2025)
“including: Communication; Training & Supervision; Record Keeping; Discharge Planning; Care Planning; Risk Assessment.”
First raised 21 Dec 2023 in Wyndham Thomas: Prevention of future deaths report. Hazard: Lack of certified safer cells outside segregation unit
Wyndham Thomas: Prevention of future deaths report (2023)
“There is no mandatory requirement for a HMP Prison to have access to a Safer Cell (one with reduced ligature points).”
This report (2025)
First raised 14 Aug 2017 in Terence Pimm. Hazard: Inadequate information sharing between police and mental health services
Terence Pimm (2017)
“The sufficiency of information sharing and coordination between the police, hospital Trust and probation service.”
This report (2025)
“Essex Police were aware that [the deceased] was under the care of the crisis mental health team and that the exacerbation of her mental health crisis was linked to a matter that was being investigated as a Hate Crime.”
First raised 4 Oct 2021 in Leon Briggs: Prevention of future deaths report. Hazard: Insufficient training on restraint safety and MCA requirements
Leon Briggs: Prevention of future deaths report (2021)
“insufficient or inadequate instruction of both police and ambulance crew about the critical issues of recognising and responding to a medical emergency and the effects of restraint including positional asphyxia.”
25 Nov 2025 · Coroner Elizabeth Gray · Cambridgeshire and Peterborough
First raised 21 Nov 2022 in Celia Marsh: Prevention of future deaths report. Hazard: Inaccurate post mortem sampling in suspected anaphylaxis cases
Celia Marsh: Prevention of future deaths report (2022)
“- If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing”
First raised 30 Nov 2018 in Thomas Nicol. Hazard: Delayed transfer of acute mental health prisoners to secure units
Thomas Nicol (2018)
“the length of time taken to transfer prisoners in acute mental health crisis to a suitable secure hospital potentially puts lives at risk”
This report (2025)
“Detention in prison of persons requiring mental health unit admission raises a concern for risk of death”
First raised 2 Mar 2018 in Emily Hartley. Hazard: Inappropriate prison environment for mental health treatment
Emily Hartley (2018)
“Prison was not the appropriate environment for someone with [the deceased]'s mental health problems.”
This report (2025)
“detention in prison prior to transfer to a secure mental health unit continues to be unavoidable.”
His Majesty's Prison and Probation Service
Derrion Adams18 Nov 2025 · Coroner Emma Brown · Birmingham and Solihull
First raised 22 Oct 2021 in Anthony Clacher: Prevention of future deaths report. Hazard: Widespread new psychoactive substances in prison
Anthony Clacher: Prevention of future deaths report (2021)
“At the time there was no policy in place regarding welfare checks to be undertaken upon somebody found under the influence of psychoactive substances and the prison staff would rely upon guidance provided by the healthcare staff.”
North Staffordshire Combined Healthcare NHS trust
Lynsey Dearden18 Nov 2025 · Coroner Emma Serrano · Staffordshire and Stoke on Trent
First raised 17 Jul 2021 in Rebecca Pykett: Prevention of future deaths report. Hazard: Lack of allocated care coordinator and psychiatric nurse appointments
Rebecca Pykett: Prevention of future deaths report (2021)
“The allocation of the Care Co-Ordinator was of concern as there was no system to ensure that a Care Co-Ordinator was actually being allocated into this role.”
Southern Health NHS Foundation Trust
Ethel Robertson17 Nov 2025 · Coroner Nicholas Walker · Hampshire, Portsmouth and Southampton
First raised 28 Jul 2023 in Kirsty Taylor: Prevention of future deaths report. Hazard: Fragmented communication between mental and physical health services
Kirsty Taylor: Prevention of future deaths report (2023)
“there is and remains a fragmented relationship between mental health and physical health services, with little inter-service connectivity.”
First raised 2 May 2024 in Frederick Boyd: Prevention of future deaths report. Hazard: Inadequate documentation of care and risk
Frederick Boyd: Prevention of future deaths report (2024)
“there was no clear system or expectation regarding the quality of checks on a resident who exhibited signs of being unwell.”
This report (2025)
Driver and Vehicle Licensing Agency
Christopher Sampson12 Nov 2025 · Coroner Adam Hodson · Birmingham and Solihull
First raised 10 Sept 2021 in Billy Warwick-Jones: Prevention of future deaths report. Hazard: Inadequate medical assessment of drivers' health conditions
Billy Warwick-Jones: Prevention of future deaths report (2021)
“Consideration should be given to more frequent, rigorous testing and to consider the duties that should be placed on the driver, their medical practitioners and also family members/carers to report changes in presentation or health to the Driver and Vehicle Licensing Agency.”
12 Nov 2025 · Coroner Adam Hodson · Birmingham and Solihull
First raised 11 Sept 2017 in Henry Prow. Hazard: Drivers failing to self-report medical conditions to DVLA
Henry Prow (2017)
“The DVLA appears to have limited mechanisms for drivers to be formally medically reviewed for the purpose of being medically fit to drive.”
This report (2025)
“I heard evidence in this inquest concerning the requirement of drivers' to self-notify the DVLA of any medical conditions that may interfere with their driving.”
11 Nov 2025 · Coroner Andrew Cox · Cornwall and the Isles of Scilly
First raised 21 Oct 2020 in Raymond Woodhouse. Hazard: Inconsistent medication administration timing
Raymond Woodhouse (2020)
“'multiple' occasions when medication was given late and three occasions when it was not given at all”
This report (2025)
“need for patients who are admitted late and unexpectedly (of which the PSII recorded there are over 1,000 annually) to have their usual medication prescribed in timely fashion.”
First raised 3 Dec 2019 in Luke Jones. Hazard: Illicit drug accessibility in prison
Luke Jones (2019)
“evidence at the inquest confirmed that the continuing availability and use of novel psychoactive substances.”
This report (2025)
“A further concern raised by the evidence relates to the lack of any attempt to cost structural cell improvements to mitigate, in at least some cells on each wing, the most obvious of ligature points in the Victorian Prison estates' cells, namely the readily accessible fixed bars at the windows.”
What was promised after the earlier report
“We recognise that prisoners may feel vulnerable during their time in custody and HMPPS uses the Assessment, Care in Custody, Teamwork (ACCT) case management approach to support people at risk of self-harm and suicide. As part of any case review, those present will consider a range of measures to mitigate risk, including the prisoner's location and whether any possessions need to be removed or returned, and this may include moving the prisoner to a cell that is more appropriate to manage their risk”
What was promised after the earlier report
“The information-sharing concordat has been reinforced. Additionally, the new Trust holds localised police liaison emergency care meetings and will ensure that the probation service is invited to improve information sharing in this regard.”
This report (2025)
“There was an evident lack of knowledge and/or concern on the part of the attending officers of the requirements of the Mental Capacity Act (MCA) 2005, particularly when it came to the decision to use force against and restrain [the deceased].”
What was promised after the earlier report
“A revised policy is due to be signed-off this year.”
This report (2025)
“a. blood samples for mast cell tryptase and sp IgE serology 2 suspected allergens b. stomach contents to be immediately stored (and/or frozen) by the pathologist for the analysis of the presence of the triggering allergen”
What was promised after the earlier report
“The Royal College of Pathologists is currently updating its autopsy practice guidelines for suspected acute anaphylaxis. The updated guidelines will include contact details for the UKFAR and direct pathologists to report fatal anaphylaxis cases to the UKFAR.”
Kirsty Walker (2018)
“The court heard that where a prisoner is assessed as being detainable under the Mental Health Act 1983, they ought to be transferred to hospital within 14 days, pursuant to the recommendations in the 2009 Bradley Report.”
This report (2025)
“The evidence I received established that, despite changes made since the Deceased's death, including the recent introduction of NHS England's "Mental Health Crisis Care for Londoners: London's Section 136 Pathway and Health Based Place of Safety Specification", it remains extremely unlikely that such a person will be granted immediate admission to a secure mental health unit.”
Martyn Stringer: Prevention of Future Deaths Report (2024)
“It is the case that a Health Based Place of Safety bed did become available but a decision was taken that due to anticipated demand for potential patients not to offer this to [the deceased].”
This report (2025)
“it remains extremely unlikely that such a person will be granted immediate admission to a secure mental health unit. This is principally because of the restricted capacity of the secure mental health unit estate”
No published response from this organisation was found for the earlier report.
No published response from this organisation was found for the earlier report.
This report (2025)
“Additionally the policy provides for the gathering of information and intelligence about the individual prisoner and the situation in the prison overall.”
No published response from this organisation was found for the earlier report.
This report (2025)
“Evidence emerged during the inquest that Mrs [name redacted] was allocated a Community Psychiatric Nurse, and key worker in November 2024 but had not received any appointments to the date of her death on the 11 March 2025.”
What was promised after the earlier report
“The revised Trust Care Management Policy provides expectation in terms of the timeframes required for allocation, assessment, care planning and review (see appendix 1). Training for all Care Co-ordinators has taken place to ensure that staff are aware of the full requirements of their role. Assurance that this process is followed is monitored through the weekly review of compliance reports, overseen by Team Leaders. This data is further reviewed at Service Manager and Associate Director Level”
This report (2025)
“If the presentation at the hospital was for a mental health related issue, then the OPMH team is likely notified as there will be contact with the psychiatric liaison service in the hospital.”
What was promised after the earlier report
“The creation of this new provider is progressing at pace (Project Fusion) with the new legal entity due to be in place by 1 April 2024.”
“During the course of the inquest it was difficult to be clear at times as to what care had been delivered or what steps had been taken because the documentation relating to care and risk was poor.”
What was promised after the earlier report
“we will require the registered provider to provide an action plan with clear timescales for completion of each action identified and will review progress against this action plan in line with our processes.”
This report (2025)
“Drivers may not self-report medical conditions due to a variety of reasons. This can be due to due to a lack of understanding, insight, or simply because someone has not explicitly told them what to do or how to do it”
What was promised after the earlier report
“we have contacted the Royal College of General Practitioners (RCGP) to alert them to these issues, so they can consider how best to raise awareness of this particular case and its implications with their members.”
Ian Harris: Prevention of Future Deaths Report (2024)
“For whatever reason the deceased did not seek the medical report from his own GP, who would have known about his medical condition and who therefore would not have been able to support the application.”
This report (2025)
“I heard evidence in this inquest concerning the requirement of drivers' to self-notify the DVLA of any medical conditions that may interfere with their driving.”
What was promised after the earlier report
“The DVLA will continue to work closely with all relevant stakeholders to raise awareness of the impact medical conditions may have on fitness to drive and continue to explore any potential options for further improvements”
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 (2025)
“I heard evidence in this inquest concerning the requirement of drivers' to self-notify the DVLA of any medical conditions that may interfere with their driving”
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 (2025)
“I heard evidence in this inquest concerning the requirement of drivers' to self-notify the DVLA of any medical conditions that may interfere with their driving.”
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”
No published response from this organisation was found for the earlier report.
“It was not surprising, therefore, that in our survey, 60% of prisoners said it was easy to get illicit drugs at Berwyn”
What was promised after the earlier report
“the Governor of Berwyn and the Regional Substance Misuse lead for HMPPS Wales have revised the prison's Drug Strategy. This primarily focuses on restricting the availability of illicit items, ensuring that there are appropriate consequences for those found in possession, and offering appropriate support for dependent users.”