Regulation 28: Report to prevent future deaths: Maia Strachan – Courts and Tribunal Judiciary

Date of report: 28 May 2019 Deceased name: Maia Strachan Coroners name: Karen Dilks Coroners Area: Newcastle Upon Tyne Category: Child Death (from 2015); Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Northumbria

Regulation 28: Report to prevent future deaths: Emily Inglis – Courts and Tribunal Judiciary

Date of report: 30 May 2019 Deceased name: Emily Inglis Coroners name: Mark Layton Coroners Area: Camarthenshire and Pembrokeshire Category: Hospital Death (Clinical Procedures and medical management) related deaths; Mental Health related deaths; Wales prevention of future deaths reports (2019

Regulation 28: Report to prevent future deaths: George Twiddy – Courts and Tribunal Judiciary

Date of report: 8 April 2019 Deceased name: George Twiddy Coroners name: David Clark Coroners Area: Portsmouth and South East Hampshire Category: Hospital Death (Clinical Procedures and medical management) related deaths; Mental Health related deaths This report is being sent

Regulation 28: Report to prevent future deaths: Royston Kemp – Courts and Tribunal Judiciary

Date of report: 2 May 2019 Deceased name: Royston Kemp Coroners name: Andrew Harris Coroners Area: London Inner (South) Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Nursing and Midwifery Council Matters

Regulation 28: Report to prevent future deaths: Alexander Davidson – Courts and Tribunal Judiciary

Date of report: 2 May 2019 Deceased name: Alexander Davidson Coroners name: Laurinda Bower Coroners Area: Nottinghamshire Category: Child Death (from 2015); Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: NHS Pathways; NHS

Regulation 28: Report to prevent future deaths: James Fletcher – Courts and Tribunal Judiciary

Date of report: 1 May 2019 Deceased name: James Fletcher Coroners name: Tim Holloway Coroners Area: Blackpool & Fylde Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Blackpool Teaching Hospitals NHS Trust

Regulation 28: Report to prevent future deaths: Barry Fullarton – Courts and Tribunal Judiciary

Date of report: 17 May 2019 Deceased name: Barry Fullarton Coroners name: Andre Rebello Coroners Area: Liverpool and Wirral Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Cheshire and Wirral NHS Trust

Regulation 28: Report to prevent future deaths: Peter Carroll – Courts and Tribunal Judiciary

Date of report: 11 March 2019 Deceased name: Peter Carroll Coroners name: Jean Harkin Coroners Area: Manchester (City) Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: MFT Matters of Concern: The coroner

Regulation 28: Report to prevent future deaths: Margaret Wilson – Courts and Tribunal Judiciary

Date of report: 11 March 2019 Deceased name: Margaret Wilson Coroners name: Jean Harkin Coroners Area: Manchester (City) Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: MFT Matters of Concern: A blood

Regulation 28: Report to prevent future deaths: Jenson Francis – Courts and Tribunal Judiciary

Date of report: 17 May 2019 Deceased name: Jenson Francis Coroners name: David Regan Coroners Area: South Wales Central Category: Child Death (from 2015); Hospital Death (Clinical Procedures and medical management) related deaths; Wales prevention of future deaths reports (2019

Regulation 28: Report to prevent future deaths: Mellin Beard – Courts and Tribunal Judiciary

Date of report: 17 May 2019 Deceased name: Mellin Beard Coroners name: Chris Morris Coroners Area: Manchester (South) Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Tameside and Glossop Care NHS Trust;

Regulation 28: Report to prevent future deaths: Ronald Clark – Courts and Tribunal Judiciary

Date of report: 8 April 2019 Deceased name: Ronald Clark Coroners name: David Clark Coroners Area: Portsmouth and South East Hampshire Category: Hospital Death (Clinical Procedures and medical management) related deaths; Product related deaths This report is being sent to:

Regulation 28: Report to prevent future deaths: Gabriele Kreichgauer – Courts and Tribunal Judiciary

Date of report: 22 February 2019 Ref: 2019-0082 Deceased name: Gabriele Kreichgauer Coroners name: Philip Barlow Coroners Area: London Inner (South) Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Barts Health NHS

Regulation 28: Report to prevent future deaths: Geoffrey Jackson – Courts and Tribunal Judiciary

Date of report: 26 February 2019 Ref: 2019-0071 Deceased name: Geoffrey Jackson Coroners name: Chris Morris Coroners Area: Manchester (South) Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Manchester University Hospitals NHS

Regulation 28: Report to prevent future deaths: Graham Jones – Courts and Tribunal Judiciary

Date of report: 18 April 2019 Ref: 2019-0131 Deceased name: Graham Jones Coroners name: Katy Skerrett Coroners Area: Gloucestershire Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Gloucestershire Hospitals NHS Trust Matters

Regulation 28: Report to prevent future deaths: Ioannis Avgousti – Courts and Tribunal Judiciary

Date of report: 24 April 2019 Ref: 2019-0135 Deceased name: Ioannis Avgousti Coroners name: Veronica Hamilton-Deeley Coroners Area: Brighton and Hove Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Brighton and Sussex

Regulation 28: Report to prevent future deaths: John Richardson – Courts and Tribunal Judiciary

Date of report: 8 March 2019 Ref: 2019-0084 Deceased name: John Richardson Coroners name: Penelope Schofield Coroners Area: West Sussex Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Sussex NHS Trust Matters

Regulation 28: Report to prevent future deaths: Jonathan Yates – Courts and Tribunal Judiciary

Date of report: 16 April 2019 Ref: 2019-0132 Deceased name: Jonathan Yates Coroners name: Katy Skerrett Coroners Area: Gloucestershire Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Gloucestershire Hospitals NHS Trust Matter

Regulation 28: Report to prevent future deaths: Justin Brown – Courts and Tribunal Judiciary

Date of report: 27 March 2019 Ref: 2019-0103 Deceased name: Justin Brown Coroners name: Jacqueline Devonish Coroners Area: Suffolk Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: NHS Suffolk Matters of concern:

Regulation 28: Report to prevent future deaths: Kathleen McGeary – Courts and Tribunal Judiciary

Date of report: 26 February 2019 Ref: 2019-0081 Deceased name: Kathleen McGeary Coroners name: Stephanie Haskey Coroners Area: Nottinghamshire Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Doncaster and Bassetlaw Teaching Hospitals