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recurance

Department of Health and Social Care

821
reports received
266
with a published response found
103
recurrence chains
331
reports in those chains
  • Katie Davies6 Jun 2014

    Coroner Alan Walsh · Manchester (West)

    No published response from this organisation found.

  • James Boylan6 Jun 2014

    Coroner Ian Smith · Cumbria (South & East)

    Response
  • Archie Hames5 Jun 2014

    Coroner Martin Fleming · Surrey

    No published response from this organisation found.

  • Liam Coleman25 May 2014

    Coroner Andrew Walker · London (North)

    No published response from this organisation found.

  • Samarjit Singh23 May 2014

    Coroner Andre Rebello · Wirral

    Response
  • Mark Bartholomew21 May 2014

    Coroner Simon Nelson · Manchester (North) · in 1 recurrence link

    No published response from this organisation found.

  • Gary Bradshaw15 May 2014

    Coroner John Pollard · Manchester (South)

    Response
    Response · 1 stated action
    2014-0232-Response-2.pdf ↗
    “All consultants have been given clear instruction that it is their responsibility to ensure that they follow up, or ensure that they have systems in place to follow up, any blood tests or any other investigation that they order.”
  • Samiyo Farah30 Apr 2014

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

    Response
  • Stephen Widman29 Apr 2014

    Coroner Ian Arrow · Plymouth, Torbay & South Devon · in 1 recurrence link

    No published response from this organisation found.

  • Janet Blackman29 Apr 2014

    Coroner Michael Burgess · West Sussex

    No published response from this organisation found.

  • Paul Ashton14 Apr 2014

    Coroner Alan Walsh · Manchester (West) · in 1 recurrence link

    Response · 3 stated actions
    2014-0170-Response-by-Department-of-Health.pdf ↗
    “the Trust is now developing such guidelines (available 14" May)”
    “England will also ensure, immediately, through Area Medical Directors, that all hospitals are made aware of the ISHLT guidelines for heart transplant patients”
    “NHS England will also ensure, immediately, through Area Medical Directors, that all hospitals are made aware of the ISHLT guidelines for heart transplant patients”
  • Lalitaben Patel13 Apr 2014

    Coroner Catherine Mason · Leicester City & South Leicestershire

    No published response from this organisation found.

  • Audrey Kelly8 Apr 2014

    Coroner John Pollard · Manchester (South) · in 2 recurrence links

    Response · 1 stated action
    2014-0155-Response-by-Department-of-Health.pdf ↗
    “The CCG have confirmed that [the deceased] had a shared record which was available to view and which included her allergy to the antibiotic specified in your report.”
    Response · 1 stated action
    2014-0155-Response-by-Department-of-Health2.pdf ↗
    “Stockport CCG is already enagaged in continual improvement work in this area. However, as a result of this investigation, the CCG is also planning the following measures: © to seek formal assurance from Mastercall about processes for new starters and contingency plans for when practitioners do not have Smartcards”
  • Oliver Hiscutt1 Apr 2014

    Coroner Sara Lewis · Manchester City

    No published response from this organisation found.

  • Coroner Jennifer Leeming · Manchester (West)

    Response
    Response · 1 stated action
    2014-0269-Response-by-Greater-Manchester-Police.pdf ↗
    “my understanding is that paramedic staff must receive training in personal safety, which is a requirement through NHS Protect, and an obligation under health and safety at work responsibilities. However, the content of that training is not stipulated, and it is down to each service to determine the content and frequency of that training. | am unclear as to the extent to which their duty of care responsibilities are understood in relation to controlling and restraining patients. We find knowledge”
    Response
  • Jackson Chadd24 Mar 2014

    Coroner Karen Henderson · Surrey

    No published response from this organisation found.

  • David Chatburn18 Mar 2014

    Coroner L J Hashmi · Manchester (North) · in 3 recurrence links

    Response · 1 stated action
    2014-0126-Response-by-Department-of-Health.pdf ↗
    “From 1 April 2014 patients with a mental health condition have had the same legal rights as physical health patients at first outpatient appointment to choose the provider that will deliver their care.”
  • Stephen Ellis5 Mar 2014

    Coroner John Pollard · Manchester (South)

    No published response from this organisation found.

  • Coroner Andrew Tweddle · County Durham & Darlington

    No published response from this organisation found.

  • Coroner Lisa Hashmi · Manchester (North)

    No published response from this organisation found.

  • Coroner Andrew Harris · London (Inner South) · in 2 recurrence links

    No published response from this organisation found.

  • Lee Curran25 Feb 2014

    Coroner Jennifer Leeming · Manchester (West)

    No published response from this organisation found.

  • Andre Matei25 Feb 2014

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

    Response · 1 stated action
    2014-0089-Response.pdf ↗
    “Commissioners and providers of maternity services should therefore ensure that professional and independent interpretation services are available in both primary- care and secondary-care settings, to ensure that all women can be confident that they can speak freely and in confidence to their maternity-care providers”
  • James Sutton24 Feb 2014

    Coroner Andrew Walker · London (North)

    No published response from this organisation found.

  • Lee Bonsall31 Jan 2014

    Coroner Jonathan Layton · Carmarthenshire & Pembrokeshire · in 1 recurrence link

    Response · 1 stated action
    2014-0044-Response-by-Department-of-Health.pdf ↗
    “NICE will be reviewing its guidelines on depression (CG90) in due course”
    Response · 1 stated action
    2014-0044-Response-by-Department-of-Health-1.pdf ↗
    “The Department and NHS England are committed to ending this imbalance. We believe that it is vital to develop and implement new access and waiting time standards to have true parity of esteem. We are committed to providing access to services and waiting times on a par with physical health.”
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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