First raised 13 Oct 2022 in Molly Russell: Prevention of future deaths report. Hazard: Algorithmic content delivery to children without safeguards
Molly Russell: Prevention of future deaths report (2022)
“That algorithms were used to provide content together with adverts.”
This report (2025)
“unless the platform providers take responsibility fortheir content and/or toxic algorithms either voluntarily or through Government action”
No published response from this organisation was found for the earlier report.
Department of Health and Social Care
Lewis Garfield28 Oct 2025 · Coroner Hassan Shah · Northamptonshire
First raised 26 May 2016 in Peter Scott. Hazard: Delayed ambulance handover at hospitals
Peter Scott (2016)
“one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals.”
This report (2025)
“I understand that nationally, the target time for handover from ambulance to hospital staff is 15 minutes.”
First raised 27 Jun 2023 in Rachel Garrett: Prevention of future deaths report. Hazard: Risk of patient absconding in acute mental health settings
Rachel Garrett: Prevention of future deaths report (2023)
“cannot invoke the Doctors or Nurses holding powers under Section 5(2) Mental Health Act (Section 5(4) for nurses).”
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 (2025)
“However, at the same time, the longest handover time at Northampton General Hospital was 5 hours and at Kettering General Hospital it was 7 hours.”
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”
Kenneth Heard: Prevention of future deaths report (2023)
“The target for hospital staff to take responsibility for the care of patients from ambulance crew is within 15 minutes of the ambulance arriving at an Emergency Department”
This report (2025)
“I understand that nationally, the target time for handover from ambulance to hospital staff is 15 minutes. In the present case, the handover from ambulance to nursing staff at John Radcliffe Hospital took 25 minutes.”
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.”
Bernard Lyon: Prevention of Future Deaths Report (2025)
“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 (2025)
“The delays getting patients from the Emergency Department (ED) into wards, causes delays taking patients from ambulances into ED, and a knock-on delay getting ambulances back out into the community. These delays persist despite the current actions to mitigate.”
This report (2025)
“It is now not possible to hold someone under s.3 at the hospital”
No published response from this organisation was found for the earlier report.