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recurance

Royal College of Psychiatrists

22
reports received
12
with a published response found
1
recurrence chains
4
reports in those chains
  • Coroner Andrew Harris · South London

    No published response from this organisation found.

  • Coroner Paul Marks · City of Kingston Upon Hull and the County of the East Riding of Yorkshire · in 2 recurrence links

    No published response from this organisation found.

  • Coroner Sarah Bourke · Inner North London

    No published response from this organisation found.

  • Coroner Andrew Harris · London South · in 2 recurrence links

    Response · 1 stated action
    2025-0123-Response-from-DHSC.pdf ↗
    “The MHRA will engage with stakeholders to ensure the regulatory documents for clozapine meet the needs of both patients and prescribers.”
  • Coroner R Brittain · Inner London North

    Response · 1 stated action
    2025-0081-Response-from-Royal-College-of-Psychiatrists-.pdf ↗
    “we have indicated that we intend to increase our visibility in the space of safe medication and prescribing. Work we are currently doing around Clozapine, which started with learnings from a death elsewhere in the country is an example of this. Although the concerns in that case were not directly aimed at the College, we recognised our responsibility to provide evidence-based advice on the safe prescribing and monitoring of Clozapine. The output of this work is due later this year.”
  • Coroner Karen Henderson · Surrey · in 2 recurrence links

    No published response from this organisation found.

  • Coroner Joanne Kearsley · Manchester North

    No published response from this organisation found.

  • Coroner Nadia Persaud · East London · in 1 recurrence link

    Response · 4 stated actions
    2023-0313-Response-from-North-East-London-Integrated-Care-Board.pdf ↗
    “We are developing a business case to secure additional funding to support improved resourcing of CAMHS services within NELFT.”
    “The business case will also include requirements to implement a face to face approach for initial CAMHS assessments.”
    “Recruitment of consultant psychiatrists is a national issue which we recognise locally - NHS North East London is working with NELFT and other providers to support recruitment and looking at innovative ways of recruiting. This work is being led by our Chief People and Culture Officer,”
    “In the short term for CAHMS for NELFT we have developed a business case for more funding to support this demand.”
    Response · 1 stated action
    2023-0313-Response-from-North-East-London-Foundation-Trust.pdf ↗
    “The Trust is determined to ensure that all patients receive care in a person-centred approach and that the patient's voice is at the centre of planning the patient's care. The Trust's expectation is that the young person's voice is heard in the triage, initial assessment, care/treatment plan, and follow-ups alongside their parents / responsible adults.”
  • Coroner Nadia Persaud · East London

    Response · 3 stated actions
    2023-0173-Response-from-NELFT.pdf ↗
    “Learning event to be arranged on this case with specific reference services were aware BDD for all staff on BDD and the importance of working with partner agencies.”
    “The Trust is planning to undertake a Quality Improvement Project on understanding why there are gaps in risk assessment and risk of accessing such management processes (a couple of examples of reoccurring treatment to [the deceased] themes), particularly when there are poor outcomes associated 30/09/2024 Assistant or attempted to share with care provided.”
    “Training department to arrange training on BDD for all staff this 01/12/2023 heard that there is a (BDD) training to to be in conjunction with SLAM who offer training in this need for training to be be offered to all specialised area.”
  • Coroner Penelope Schofield · West Sussex · in 1 recurrence link

    Response · 1 stated action
    2023-0144-Response-from-NHS-England.pdf ↗
    “The Trust has also shared with us a helpful learning briefing on Section 17 leave from inpatient wards. This will be shared with the national Regulation 28 Working Group regional representatives for dissemination across the seven NHS regions, to raise awareness of the issue with their Trusts and to encourage best practice.”
  • Coroner Paul Marks · East Riding and Hull · in 1 recurrence link

    Response · 1 stated action
    2022-0408-Response-from-Department-of-Health.pdf ↗
    “I am therefore taking steps to raise this issue with HSC Trust Chief Executives and relevant professional bodies, in order to ensure that the appropriate action is taken to address this point.”
  • Coroner Rachael Griffin · Dorset · in 3 recurrence links

    Response · 1 stated action
    2022-0222-Response-from-Royal-College-of-Psychiatrists.pdf ↗
    “The College very much recognise the issues you raise in relation to the lack of effective and consistent communication between services for people with neurological conditions and mental illness.”
  • Coroner Sean Cummings · Bedfordshire and Luton

    No published response from this organisation found.

  • Coroner Joanne Kearsley · Manchester North · in 1 recurrence link

    Response · 1 stated action
    2021-0433-Response-regarding-Nichola-Lomax.pdf ↗
    “The Department will continue to support and assure this work to progress against key actions, including ensuring better awareness of eating disorder training and continuing professional development.”
  • Coroner Caroline Jones · Cambridgeshire and Peterborough

    Response · 1 stated action
    2021-0260-Response-from-Royal-College-of-Psychiatrists-1.pdf ↗
    “We will look for opportunities to do this in the near future”
  • James Frankish9 Oct 2019

    Coroner Elizabeth Didcock · Nottinghamshire

    No published response from this organisation found.

  • Coroner Fiona Wilcox · London Inner (West)

    No published response from this organisation found.

  • Deidre Harvey8 Aug 2018

    Coroner Christopher Woolley · South Wales Central

    Response · 1 stated action
    2018-0266-Response-by-NHS-Improvement.pdf ↗
    “We stand ready to support the MHRA in ensuring any future changes to monitoring reach all appropriate healthcare professionals and patients, including through our shared national network of Medication Safety Officers.”
    Response · 1 stated action
    2018-0266-Response-by-MHRA.pdf ↗
    “We have further considered your concerns that there may be other dependent persons suffering from lupus (or other conditions for which hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of hydroxychloroquine in their system unbeknown to their carers. Some”
  • Jonathan Zucker26 Jun 2017

    Coroner Andrew Walker · London (North) · in 1 recurrence link

    Response · 1 stated action
    2017-0433-Response-by-PSYCH.pdf ↗
    “The College is aware that CPA policy can be interpreted and applied differently across the country. Ideally a care co-ordinator will be able to negotiate patient discharges and their integration into the care of a new team. However, there are circumstances in which this is not straight-forward, e.g. if a section is ending or a person is being discharged from hospital.”
  • Coroner Karen Henderson · Surrey

    Response · 4 stated actions
    2016-0424-Response-by-RCPSYCH.pdf ↗
    “I shall liaise with the Chair of our Special Committee for Psychopharmacology to publicize these matters to the members and fellows of the RCPsych”
    “I shall liaise with the Chair of the Faculty of Old-Age Psychiatry to determine the best way to raise these issues with old-age psychiatrists”
    “We will review our continuing medical education initiatives to ensure that this issue is comprehensively covered in RCPsych material”
    “I shall inform the Presidents of the Royal Colleges of Physicians and General Practitioners, by copy of this letter, of our plans and will be ready to work with them in any suitable joint ventures”
    Response · 1 stated action
    2016-0424-Response-by-MHRA.pdf ↗
    “We have reviewed the product information (Summary of Product Characteristics [SmPC] and Patient Information Leaflet) of olanzapine, mirtazapine and indapamide and are satisfied that all three contain appropriate warnings regarding the risk of QT prolongation, particularly when used with other medication that also causes QT prolongation.”
  • Samiyo Farah30 Apr 2014

    Coroner Lisa Hashmi · Manchester (North) · in 3 recurrence links

    No published response from this organisation found.

  • Kirabo Kiwanuka3 Mar 2014

    Coroner Andrew Harris · London (Inner South)

    No published response from this organisation found.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error