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: 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

Regulation 28: Report to prevent future deaths: Kerry Hunter – Courts and Tribunal Judiciary

Date of report: 23 April 2019 Ref: 2019-0137 Deceased name: Kerry Hunter Coroners name: Nigel Parsley Coroners Area: Suffolk Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Norfolk & Suffolk NHS Trust

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

Date of report: 25 April 2019 Ref: 2019-0127 Deceased name: Mildred Clark Coroners name: Sonia Hayes Coroners Area: Kent (North-East) Category: Emergency services related deaths (2019 onwards); Hospital Death (Clinical Procedures and medical management) related deaths This report is being

Regulation 28: Report to prevent future deaths: Nathan Mooney – Courts and Tribunal Judiciary

Date of report: 26 February 2019 Ref: 2019-0072 Deceased name: Nathan Mooney Coroners name: Chris Morris Coroners Area: Manchester (South) Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Department for Health and

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

Date of report: 15 April 2019 Ref: 2019-0134 Deceased name: Nyall Brown Coroners name: Jacqueline Lake Coroners Area: Norfolk Category: Mental Health related deaths; Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Norfolk

Regulation 28: Report to prevent future deaths: Steffan Kuenzel – Courts and Tribunal Judiciary

Date of report: 29 April 2019 Ref: 2019-0143 Deceased name: Steffan Kuenzel Coroners name: Sarah Bourke Coroners Area: London Inner (North) 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: Stephen Harte – Courts and Tribunal Judiciary

Date of report: 1 February 2019 Ref: 2019-0077 Deceased name: Stephen Harte Coroners name: James Bennett Coroners Area: Birmingham and Solihull 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: Terence Bradfield – Courts and Tribunal Judiciary

Date of report: 11 March 2019 Ref: 2019-0086 Deceased name: Terence Bradfield Coroners name: Deborah Archer Coroners Area: Plymouth Torbay and South Devon Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: University

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

Date of report: 17 April 2019 Deceased name: Megan Jones Coroners name: Caroline Sumeray Coroners Area: Isle of Wight Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Hampshire and Isle of Wight

Regulation 28: Report to prevent future deaths: Nathan Cooke – Courts and Tribunal Judiciary

Date of report: 17 April 2019 Ref: 2019-0125 Deceased name: Nathan Cooke Coroners name: Caroline Sumeray Coroners Area: Isle of Wight Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Hampshire and Isle

Regulation 28: Report to prevent future deaths: Roger Neaves – Courts and Tribunal Judiciary

Date of report: 18 April 2019 Deceased name: Roger Neaves Coroners name: Ian Arrow Coroners Area: Plymouth Torbay and South Devon Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Derriford Hospital Trust

Regulation 28: Report to prevent future deaths: Alice Dixon – Courts and Tribunal Judiciary

Date of report: 5 April 2019 Deceased name: Alice Dixon Coroners name: Simon Wickens Coroners Area: Surrey Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Ashford and St Peter’s Hospitals NHS Trust

Regulation 28: Report to prevent future deaths: Tarek Chowdhury – Courts and Tribunal Judiciary

Date of report: 2 April 2019 Deceased name: Tarek Chowdhury Coroners name: Richard Furniss Coroners Area: London (West) Category: Hospital Death (Clinical Procedures and medical management) related deaths; State Custody related deaths This report is being sent to: Home Office;

Regulation 28: Report to prevent future deaths: Anthony Buckingham – Courts and Tribunal Judiciary

Date of report: 9 April 2019 Deceased name: Anthony Buckingham Coroners name: Daniel Sharpstone Coroners Area: Suffolk Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Norfolk and Suffolk NHS Trust At the

Regulation 28: Report to prevent future deaths: Nora Bruton – Courts and Tribunal Judiciary

Date of report: 25 March 2019 Deceased name: Nora Bruton Coroners name: Adam Hodson Coroners Area: Birmingham and Solihull Category: Alcohol, drug and medication related deaths; Mental Health related deaths; Hospital Death (Clinical Procedures and medical management) related deaths This

Regulation 28: Report to prevent future deaths: Tamsin Grundy – Courts and Tribunal Judiciary

Date of report: 13 March 2019 Ref: 2019-0088 Deceased name: Tamsin Grundy Coroners name: Jacqueline Lake Coroners Area: Norfolk Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Norfolk & Suffolk NHS Trust