A senior coroner will issue a Prevention of Future Deaths report after an inquest found gaps in maternity care for a pregnant woman between her release from prison and her recall.
An inquest jury found that the death of a life-sentence prisoner at HMP Frankland was drug-related, and the coroner has urged the prison to apply its visits policy more consistently.
A senior coroner found that missing heart medication played a part in the death of George Haldenby, and warned that gaps in out-of-hours prescribing and CPR training could cost more lives.
A coroner has told the Ministry of Justice that housing people convicted of sexual offences alongside other prisoners could lead to more deaths. The ministry says the approach supports rehabilitation.
An assistant coroner found that staff at HMP Nottingham did not know, or did not understand, the psychological history of the man who killed Jonathan Thornton in June 2024.
A coroner has issued a prevention of future deaths report after CCTV showed prisoners silencing a cell’s emergency bell in the hour before Thomas Ruggiero was found unresponsive.
Paul Thompson took his own life four days after leaving the prison. The coroner said arrangements for mental health care for people released out of hours were inadequate.
Jurors criticised the prison’s failure to deal with the availability of drugs and an inadequate search of Simon Ludlow’s cell before he died in November 2023.
