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recurance

Anthony McManus

31 Oct 2016 · Coroner Thomas Osborne · Milton Keynes

This report repeats 1 earlier warning. See the linked reports.

The coroner's concerns

  1. 1. nighttime observation system

    “The system of observations carried out within the unit, particularly at night is in need of reform”

Linked reports

Repeats an earlier warningNeil Carter5 Mar 2014 · 2 years 8 months earlier
Identical hazardConfidence 0.90 · high

Earlier report

“There were repeated failures to perform basic nursing observations”
Original on judiciary.uk ↗

This report

“The system of observations carried out within the unit, particularly at night is in need of reform.”
Full chain: Inadequate nighttime patient observation documentation

Responses

No published response was found on judiciary.uk.

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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

Anthony McManus · Recurance