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

Date of report: 26 September 2019 Deceased name: John Shrosbree Coroners name: Tom Osborne Coroners Area: Milton Keynes Category: Hospital Death (Clinical Procedures and medical management) related death; This report is being sent to: Milton Keynes University Hospital Matters of

Regulation 28: Report to prevent future deaths: Zona Tebbs – Courts and Tribunal Judiciary

Date of report: 19 July 2019 Deceased name: Zona Tebbs Coroners name: Nicola Mundy Coroners Area: South Yorkshire (East) Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Public Health England, Yorkshire and

Regulation 28: Report to prevent future deaths: Xander Curran-Pass – Courts and Tribunal Judiciary

Date of report: 24 July 2019 Deceased name: Xander Curran-Pass Coroners name: Alison Mutch Coroners Area: Manchester (South) Category: Hospital Death (Clinical Procedures and medical management) related deaths; Child Death (from 2015) This report is being sent to: Stepping Hill

Regulation 28: Report to prevent future deaths: Gladys Sayles – Courts and Tribunal Judiciary

Date of report: 26 July 2019 Ref: 2019-0253 Deceased name: Gladys Sayles Coroners name: Martin Fleming Coroners Area: West Yorkshire (West) Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Leeds Teaching Hospitals

Regulation 28: Report to prevent future deaths: Alex Blake – Courts and Tribunal Judiciary

Date of report: 29 July 2019 Deceased name: Alex Blake Coroners name: Andrew Harris Coroners Area: London Inner (South) Category: Alcohol, drug and medication related deaths; Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent

Regulation 28: Report to prevent future deaths: Allan Joslin – Courts and Tribunal Judiciary

Date of report: 17 July 2019 Ref: 2019-0241 Deceased name: Allan Joslin Coroners name: Lydia Brown Coroners Area: Exeter and Greater Devon Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: NHS England

Regulation 28: Report to prevent future deaths: Lindsey Bailey – Courts and Tribunal Judiciary

Date of report: 11 July 2019 Deceased name: Lindsey Bailey Coroners name: Andrew Haigh Coroners Area: Staffordshire (South) Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Midlands Partnership NHS Trust Matters of

Regulation 28: Report to prevent future deaths: Miriam Tighe – Courts and Tribunal Judiciary

Date of report: 4 July 2019 Deceased name: Miriam Tighe Coroners name: Rachel Galloway Coroners Area: Manchester (West) Category: Care Home Health related deaths; Community health care related deaths; Hospital Death (Clinical Procedures and medical management) related deaths This report

Regulation 28: Report to prevent future deaths: Andrew McCall – Courts and Tribunal Judiciary

Date of report: 1 July 2019 Deceased name: Andrew McCall Coroners name: Andrew Barkley Coroners Area: Stoke-on-Trent & North Staffordshire Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: NHS England Matters of

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

Date of report: 3 July 2019 Deceased name: John Doyle Coroners name: Nadia Persaud Coroners Area: London (East) Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: North East London NHS Trust; Goodmayes

Regulation 28: Report to prevent future deaths: Jennifer Witney – Courts and Tribunal Judiciary

Date of report: 3 July 2019 Deceased name: Jennifer Witney Coroners name: Andrew Cox Coroners Area: Cornwall and the Isles of Scilly Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: NHS England;

Regulation 28: Report to prevent future deaths: Maureen Martin – Courts and Tribunal Judiciary

Date of report: 26 June 2019 Deceased name: Maureen Martin Coroners name: Andrew Haigh Coroners Area: Staffordshire South Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: University Hospitals of Derby and Burton

Regulation 28: Report to prevent future deaths: Ezra Boulton – Courts and Tribunal Judiciary

Date of report: 1 July 2019 Deceased name: Ezra Boulton Coroners name: Samantha Marsh Coroners Area: Portsmouth and South East Hampshire Category: Child Death (from 2015); Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent

Regulation 28: Report to prevent future deaths: Noah Lomax – Courts and Tribunal Judiciary

Date of report: 24 May 2019 Ref: 2019-0186 Deceased name: Noah Lomax Coroners name: Angharad Davies Coroners Area: South Yorkshire (West) Category: Child Death (from 2015); Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent

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

Date of report: 13 June 2019 Deceased name: Sebastian Clark Coroners name: Sean Cummings Coroners Area: London (West) Category: Hospital Death (Clinical Procedures and medical management) related deaths; Child Death (from 2015) This report is being sent to: Royal College

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

Date of report: 22 May 2019 Deceased name: Jonathan McCarthy Coroners name: Roger Hatch Coroners Area: North West Kent Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Maidstone & Tonbridge Wells NHS

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