Worcestershire Acute Hospitals NHS Trust
Mathew Bailey12 Aug 2026 · Coroner David Reid · Worcestershire
First raised 13 Feb 2015 in Francoise Snape. Hazard: Missed opportunity for appropriate VTE risk management
Francoise Snape (2015)
“No VTE assessment was ever made of Mrs [name redacted]. The explanation given oy was that staff were too busy to complete the form”
This report (2026)
“(b) a venous thromboembolism ( VTE ) assessment was carried out, which identified that the deceased had an identified risk of suffering a VTE event and prescribed compression stockings to mitigate that risk.”
No published response from this organisation was found for the earlier report.
Department of Health and Social Care
Pamela Hindley10 Aug 2026 · Coroner Guy Davies · Cornwall & the Isles of Scilly
First raised 23 Nov 2023 in Kenneth Heard: Prevention of future deaths report. Hazard: Insufficient social care provision leading to discharge delays
Kenneth Heard: Prevention of future deaths report (2023)
“The root cause for ambulance delays was found to be the lack of social care provision in Cornwall, whether care packages or beds in care homes.”
27 Jul 2026 · Coroner David Reid · Worcestershire
First raised 20 Sept 2022 in Gary McDonald: Prevention of future deaths report. Hazard: Lack of follow-up on mental health history and drug overdose
Gary McDonald: Prevention of future deaths report (2022)
“During his initial healthcare screening appointment on the evening he arrived at HMP Hewell ( 25.3.21 ) and his secondary healthcare screening appointment the following day, Mr [name redacted] denied any mental health issues, and denied any current thoughts of suicide or self-harm.”
First raised 11 Aug 2020 in Moses Boardman. Hazard: Lack of transport suitability assessment for changing patient conditions
Moses Boardman (2020)
“The failure of RLH transport staff to properly assess the suitability of the venue that a patient is being taken to.”
Tameside and Glossop Integrated Care NHS Foundation Trust
Margaret Murphy21 Jul 2026 · Coroner Chris Morris · Greater Manchester (South)
First raised 11 Jun 2025 in Lila Marsland: Prevention of Future Deaths Report. Hazard: Disjointed clinical information system leading to data loss risk
Lila Marsland: Prevention of Future Deaths Report (2025)
“over the course of almost 10 hours in hospital, [the deceased]'s history and details of examinations and assessments undertaken were recorded on a mixture of various analogue and digital systems in operation in different parts of the Trust, leading to a risk of vital clinical information being lost in the system.”
First raised 31 Jan 2014 in Shaun Elliott. Hazard: Missing person coordinator absent weekends and insufficient 24/7 PolSA coverage
Shaun Elliott (2014)
“The evidence revealed that a missing person coordinator was in post but not on duty at weekends.”
This report (2026)
“The inability of police forces to provide 24/7 365 day coverage of PolSA responsibilities is being impeded by: (1) insufficient provision of training places, and (2) the number of training places made available”
Mid and South Essex NHS Foundation Trust
Margaret Templeman20 Jul 2026 · Coroner Rebecca Mundy · Essex
First raised 9 Sept 2020 in Frederick Terry. Hazard: Inaccurate and incomplete clinical records
Frederick Terry (2020)
“Accuracy of record keeping - Training and procedures in respect of how communications should occur between all clinical personnel in the delivery theatre”
First raised 22 Sept 2017 in Shahbaz Salim. Hazard: Standing water on road leading to hydroplaning
Shahbaz Salim (2017)
“The scene of the collision is in a natural 'bowl' and that, unless effectively drained, it is a point at which standing water will accumulate during and/or after heavy rainfall”
This report (2026)
“The centralised location of these collisions suggests that there may be ongoing issues with drainage on this section of the road.”
His Majesty's Prison and Probation Service
Johnpaul Digweed29 Jun 2026 · Coroner Christopher Long · Lancashire and Blackburn with Darwen
First raised 14 Oct 2024 in Stephen Sleaford: Prevention of Future Deaths Report. Hazard: Obscured observation panels hinder monitoring
Stephen Sleaford: Prevention of Future Deaths Report (2024)
“The evidence revealed that despite clear instruction to officers, by way of Notices to Staff from senior management at the prison, to the effect that obscuring cell door observation panels on the inside by prisoners was not permitted practice and was to be challenged and remedied, routine practice by prison officers meant observation panels were permitted to be obscured, without challenge or sanction.”
First raised 2 Dec 2019 in Sidney Baker. Hazard: Inaccurate and inconsistent care plan entries and record keeping
Sidney Baker (2019)
“There were concerns that entries contained in Mr [name redacted] care plan were incorrect, including vital information contained on his weight monitoring sheet. Furthermore, the general quality of record keeping was poor.”
First raised 31 Jan 2018 in Aaron Nordass-Lacey. Hazard: Excessive speeding near school crossing
Aaron Nordass-Lacey (2018)
“The road where the incident occurred that lead to [the deceased]'s death, the A35 Barrack Road, Christchurch, Dorset is a road which has a speed limit of 30 miles per hour. Evidence was given that people regularly drive at excessive speeds on this road.”
Royal College of Obstetricians and Gynaecologists
Nola-Reign Morgan24 Jun 2026 · Coroner Martin Lanchester · Gwent
First raised 16 Feb 2015 in Mohammed Yousaf. Hazard: Lack of national guidance for antenatal fetal monitoring
Mohammed Yousaf (2015)
“Whilst Pennine Acute Hospitals NHS Trust has now established its own local guidelines based upon recent research conducted in Bristol, there are no national guidelines on how to interpret and/or classify antenatal (as opposed to intra-partum) CTG tracings.”
First raised 16 Apr 2015 in Robert Payne. Hazard: Unwitnessed fall during ward transfer
Robert Payne (2015)
“He was transferred between wards at 1am in the morning in circumstances in which it appears no transfer document was completed and fell in circumstances in which the fall was not witnessed.”
This report (2026)
“Delay in transferring between Antenatal and HDU wards. The delay in transferring [the deceased]'s mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised.”
Department of Health and Social Care
Geoffrey Fuller18 Jun 2026 · Coroner Guy Davies · Cornwall & the Isles of Scilly
First raised 27 Feb 2020 in Mohan Acharya. Hazard: Overcrowded emergency department increases patient mortality
Mohan Acharya (2020)
“Emergency department crowding is associated with increased mortality amongst admitted patients;”
This report (2026)
“On the day of Mr [name redacted] ambulance delay, RCHT ED was accommodating 105 patients. ED has a capacity of 42 patients.”
Department of Health and Social Care
Isabelle Bridie Sapherson-Moralee18 Jun 2026 · Coroner Brendan Joseph Allen · Dorset
First raised 19 Aug 2025 in Gemma Weeks: Prevention of future deaths report. Hazard: Ketamine use risks insufficiently recognised
Gemma Weeks: Prevention of future deaths report (2025)
“Ketamine is a controlled drug of class B. There is a perception in naïve users that this signifies "lesser" risks associated with using ketamine as compared with class A drugs.”
This report (2026)
“The root cause of the need for the rapid discharge event was inadequate social care provision, this being an ongoing situation.”
What was promised after the earlier report
“we published our 'Delivery plan for recovering urgent and emergency care services' which aims to deliver sustained improvements in waiting times. Our ambitions for this year are to improve A&E waiting times to 78% of patients to be admitted, transferred, or discharged from A&E within four hours by March 2025, and to reduce Category 2 ambulance response times to 30 minutes on average across this fiscal year.”
Andrew Waters: Prevention of Future Deaths Report (2025)
“Insufficient social care provision leading to large numbers of patients in hospital who are otherwise fit for discharge, thereby impeding patient flow through hospital.”
This report (2026)
“The court found significant numbers of patients in hospital who are medically fit for discharge and with no reason to reside in hospital (NCTR) but cannot be discharged due to lack of available social care provision (whether commissioned by social services or NHS).”
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.”
James Smith: Prevention of Future Deaths Report (2025)
“Insufficient social care provision leading to large numbers of patients in hospital who are otherwise fit for discharge, thereby impeding patient flow through hospital,”
This report (2026)
“The root cause of the need for the rapid discharge event was inadequate social care provision, this being an ongoing situation.”
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.”
This report (2026)
“the agency nurse who conducted the deceased's initial healthcare screening appointment on his arrival at HMP Hewell may not have looked at his PER, either because he did not have access to a copy of it, or because he had not been trained to ensure that he looked at it.”
This report (2026)
“There appears to have been no mechanism to review the suitability of the chosen transport and crew for a patient whose condition has materially changed from the point of booking to the point of transfer.”
What was promised after the earlier report
“The departure lounge changed its practice to ensure that the staff document in the patients electronic record in line with trust practice. Confirmation of this has been detailed within the departments most recent version of the Standard Operating Procedure (SOP). At the inquest you were shown this SOP in draft form but | can update you now to say that it has now been signed off by the Royal London Hospital's Executive Board.”
This report (2026)
“Having reviewed Miss [name redacted] in the Same Day Emergency Care Unit on 5 October 2025, the Orthopaedic Senior House Officer wrote their notes in a Trauma and Orthopaedic 'Tracker', not routinely accessible to clinicians working in other specialities.”
No published response from this organisation was found for the earlier report.
This report (2026)
“During the course of this investigation I heard evidence of significant deficiencies in the maintenance of clinical records relating to hydration, nutrition, communication, observations, medication management and aspects of clinical decision making.”
What was promised after the earlier report
“The guidelines have been updated to reflect the Royal College of Obstetricians and Gynaecologists recent guideline on Assisted Vaginal Birth (April, 2020)1, this includes a risk assessment to assist with decision making for an assisted vaginal birth, an improved documentation pro forma following an assisted vaginal birth and reference to ensuring that the baby's head is checked immediately at birth for signs of trauma when obstetric instruments have been applied.”
Laura-Jane Seaman: Prevention of Future Deaths Report (2024)
“d. Communication issues with Trust staff and sharing of information”
This report (2026)
“I am concerned that the documentation and communication failures identified in this case may not be confined to a single ward, clinical team or hospital site.”
What was promised after the earlier report
“All Mid and South Essex Hospital NHS Foundation Trust ('MSE') sites have now adopted an electronic prescribing and medication administration (EPMA) platform. EPMA facilitates team members across specialties to record accurately and contemporaneously in one place. The system allows all registered users to clearly see what other medications have been administered and by whom. Staff details are visible against the record so that each interaction is name and date stamped within the patient record.”
What was promised after the earlier report
“The drainage scheme is progressing as planned through the design and development phases with an estimated start date on the A46 in February 2018. The work will take place over a period of approximately 20 weeks with a planned completion date of June 2018.”
Josie Archer-Smith: Prevention of future deaths report (2022)
“The crash location is at the bottom of an incline on the M20 motorway which normally would not cause an issue, however the road also has a camber which causes water to run across the carriageway rather than draining into either the central reservation of the drain on the hard shoulder.”
This report (2026)
“Despite this fatal collision having occurred in December 2025, the topographic and drainage surveys are not yet available and no works other than "minor works for overburden removal" have taken place”
What was promised after the earlier report
“170 metres of combined kerb drainage jetted, 200 metres x 2 Acco drains jetted and a full CCTV drainage survey carried out”
James Scott: Prevention of Future Deaths Report (2025)
“(2) Whilst the precise cause of the flooding is unknown, a more regular maintenance schedule may have prevented the buildup of vegetation within the gullies and therefore assisted in the drainage of the heavy rainfall experienced that day thus reducing the amount of surface water present on the road”
This report (2026)
“The centralised location of these collisions suggests that there may be ongoing issues with drainage on this section of the road.”
This report (2026)
“Evidence was heard that there is a regular practice of prisoner's covering their observation panels in their cell doors at HMP Garth. Despite Governor's Orders and staff instructions being in place requiring staff to take steps to ensure any inundation is removed, this was not being adhered to.”
This report (2026)
“(1) The record keeping in the home appeasers to be inaccurate and inconsistent”
What was promised after the earlier report
“We will carry out a further comprehensive inspection within 12 months, to ensure action has been taken and the provider is no longer in breach.”
John Dickinson: Prevention of future deaths report (2021)
“The record keeping was inconsistent and lacked detail on general wellbeing.”
This report (2026)
“The record keeping in the home appeasers to be inaccurate and inconsistent”
What was promised after the earlier report
“The provider has indicated they have also reviewed the quality of their own documentation and care records. In relation to food records, in addition to improved documentation, staff have also received additional training.”
This report (2026)
“Has the correct speed limit been fixed for the stretch of road where the collision has occurred”
This report (2026)
“National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected.”
No published response from this organisation was found for the earlier report.
No published response from this organisation was found for the earlier report.
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.”
This report (2026)
“Significant handover delays 1. The court noted that the NHS national target is for ambulances to handover patients to hospital is within 15 minutes of arrival.”
What was promised after the earlier report
“have been strengthened, with the Division of Urgent Care now assuming full responsibility for the Corporate Site management team to ensure a full and co-ordinated focus is maintained on safe patient flow and ambulance handover delays. Other”
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)
“On arrival at Royal Cornwall Hospital (RCHT), Mr [name redacted] spent a further 2 hours and 52 minutes before being handed over to the emergency department.”
Kenneth Heard: Prevention of future deaths report (2023)
“The root cause for ambulance delays was found to be the lack of social care provision in Cornwall, whether care packages or beds in care homes.”
This report (2026)
“The court found there was insufficient bed availability on acute wards which was attributable to significant numbers of patients in hospital with no reason to reside (NCTR), these being patients who are medically optimised but cannot be discharged due to lack of onward care support.”
What was promised after the earlier report
“we published our 'Delivery plan for recovering urgent and emergency care services' which aims to deliver sustained improvements in waiting times. Our ambitions for this year are to improve A&E waiting times to 78% of patients to be admitted, transferred, or discharged from A&E within four hours by March 2025, and to reduce Category 2 ambulance response times to 30 minutes on average across this fiscal year.”
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)
“These handover delays lead to the unavailability of ambulances to respond to emergency calls. Furthermore, the average handover delays conceal spikes such as that which led to the long delay in this case.”
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”
Dennis Harry: Prevention of Future Deaths Report (2024)
“There is a direct connection between the risk of excessive ambulance delays and inadequate social care provision, community hospital provision and primary healthcare support for discharges in Cornwall.”
This report (2026)
“The court noted the main cause for the numbers of NCTR patients was insufficient social care provision, whether commissioned by social services or NHS.”
Kevin Woods: Prevention of Future Deaths Report (2024)
“Continuing average handover delays (and therefore response delays) which create a risk of future deaths. The averages conceal spikes of delayed handover and ambulance response times which increase the risk of mortality.”
This report (2026)
“These handover delays lead to the unavailability of ambulances to respond to emergency calls. Furthermore, the average handover delays conceal spikes such as that which led to the long delay in this case.”
What was promised after the earlier report
“developing local partnership working between the NHS and social care and making sure people get the right support from health and social care services to return home as soon as possible”
Junior Powell: Prevention of Future Deaths Report (2024)
“delay in discharge for patients ready to be discharged due to lack of suitable social care in the community is causing congestion”
This report (2026)
“The court noted the main cause for the numbers of NCTR patients was insufficient social care provision, whether commissioned by social services or NHS.”
No published response from this organisation was found for the earlier report.
Dorothy Reid: Prevention of Future Deaths Report (2025)
“there are a significant number deaths associated with long waits in the emergency department”
This report (2026)
“Such long delays increase the risk of mortality.”
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)
“The court noted that the NHS national target is for ambulances to handover patients to hospital is within 15 minutes of arrival.”
Andrew Waters: Prevention of Future Deaths Report (2025)
“Significant handover delays leading to ambulance resources being tied up at hospital with increased risk in mortality for patients in the community waiting for emergency ambulances”
This report (2026)
“Significant handover delays”
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)
“The evidence given to the inquest indicated 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)
“Significant handover delays”
James Smith: Prevention of Future Deaths Report (2025)
“Insufficient social care provision leading to large numbers of patients in hospital who are otherwise fit for discharge, thereby impeding patient flow through hospital”
This report (2026)
“Data indicates that RCHT have been failing to meet the 4-hour target for a significant number of patients.”
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.”
This report (2026)
“There is limited research on the addictiveness of ketamine and the consequences of chronic ketamine use.”
No published response from this organisation was found for the earlier report.