2026

Concerns summary (AI summary) Therapeutic observations were not accurately recorded due to Wi-Fi signal issues, and there was no care plan in place to address the physical health conditions, such as sleep apnoea, associated with long-term mental health medication.

Concerns summary (AI summary) Prolonged storage of household items in the main living area created a hazard for an elderly tenant, and there were no clear policies or time limits governing such storage or mitigating steps.

Concerns summary (AI summary) The detachment of a wheelchair seat cushion after only 9 months raised concerns about the robustness of the attachment method, and a lack of assessment of the vehicle restraint system's fit contributed to the deceased being thrown into the footwell during transport.

Concerns summary (AI summary) Difficulties locating the appropriate cardiac arrest guidance on the JRCALC app, the inability of paramedics to comply with respiratory arrest guidelines, and insufficient Naloxone supplies in ambulances were identified as concerns.

Concerns summary (AI summary) The coroner raises concerns that the £250 per week allowance for reasonable living expenses under Proceeds of Crime Act Restraint Orders, which has not been reviewed since 2009, is insufficient given the increased cost of living, especially for those with dependents.

Concerns summary (AI summary) The coroner noted that non-urgent referrals to the Single Point of Access (SPA) for mental health support may take up to 14 days to triage, and referrals could come from individuals without mental health experience.

Concerns summary (AI summary) Information sharing barriers between the Community Forensic Team and prison healthcare, as well as between prison healthcare and operational prison staff, were identified as concerns. The limited and broad categorisation of alerts on NOMIS/DPS was also raised as an issue.

Concerns summary (AI summary) The coroner expressed concern that patients receiving private care for skin cancers may receive inferior care compared to NHS patients, due to a lack of mandated care standards and access to specialist skin MDTs.

Concerns summary (AI summary) The report identifies concerns about the potential for incorrect medication dosages to be prescribed or administered, the risk of patients being discharged back to prison from QEH without an MDT meeting, and healthcare staff being unable to access a prisoner's cell at night.

Concerns summary (AI summary) Suicide prevention training is not mandatory for frontline practitioners within Warwickshire Children’s Services, potentially leading to variability in practice when responding to indications of self-harm or suicidal thoughts.

Concerns summary (AI summary) A conflict exists between Building Regulations and BSI Standards regarding the measurement of barrier heights when a wall or parapet is used as guarding, and the guidance does not mention horizontal railings being a climbing risk for adults and children over 5 years old.

Concerns summary (AI summary) A traffic management plan was incorrectly implemented due to inaccurate map coordinates, leading to improper signage and a road traffic collision; special signage was unavailable due to the plan flip.

Concerns summary (AI summary) Child death investigation teams may be too easily reassured by well-presented homes, leading to perfunctory scene examinations and lost forensic opportunities.

Concerns summary (AI summary) Front line police officers receive regular refresher training on first aid, but no similar provision is in place for mental health first aid training.

Concerns summary (AI summary) The initial Patient Safety Incident Investigation lacked robustness and did not appear to have been revisited in light of emerging family concerns; proactive communication to families of issues or obstructions to bed availability and reinforcement of safety plans should be a central feature of daily Patient Flow Meetings; it remains unclear how a lack of face-to-face psychiatric review can be escalated.

Concerns summary (AI summary) Observations on Ellis Ward may not be carried out in accordance with Trust policy, with staff not always attempting to engage with patients during observations.