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: 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: 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

Failures In Communication Or Follow-Up Of Unexpected Significant Radiological Findings – Healthcare Safety Investigation Branch

Healthcare Safety Investigation Branch report demonstrating where technology could play a pivotal role in reducing harm caused by failures in communication or follow-up of unexpected significant radiological findings. The investigation also makes three other recommendations in relation to following up

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: 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