“identified during an investigation which, in the coroner’s opinion, give rise to a risk…”
Dated 7 May 2026, from the coroner for Birmingham and Solihull. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedOrganisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated7 May 2026
- Deadline2 Jul 2026
- Published on judiciary.uk17 Jul 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Department of Health and Social Care | Response publishedPublished on judiciary.uk in July 2026. |
| NHS Birmingham and Solihull Integrated Care BoardNamed in the report as “Birmingham and Solihull Integrated Care Board” | Response publishedPublished on judiciary.uk in July 2026. |
The coroner’s concerns
identified during an investigation which, in the coroner’s opinion, give rise to a risk of future deaths. It is designed to promote clarity, ensure that reports are formulated in a way that enables recipients to understand and address the concerns raised, and to support good practice across jurisdictions. The template does not fetter judicial independence: coroners remain responsible for determining the facts, identifying the matters of concern, and drafting reports that accurately reflect the circumstances of each individual case. The template may be adapted as necessary to ensure that the report properly and precisely records the coroner’s views. In accordance with the Chief Coroner’s PFD Publication Policy (2026) any applications for redactions to content or general publication of the report must be sent to the coroner. The coroner will provide the representations to the Chief Coroner for a decision. REPORT TO PREVENT FUTURE DEATHS REGULATION 28 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 (Please do not include any living persons’ names in this document, in accordance with the Chief Coroner’s PFD Publication Policy (2026)) CORONER 1 I am Louise Hunt HM Senior Coroner for the coroner area of Birmingham and Solihull DATE OF REPORT 2 7th May 2026 3 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. THIS REPORT IS BEING SENT TO 1. Department of health and social care 4 2. Birmingham and Solihull Integrated care board. You are under a duty to respond to this report within 56 days of the date of this report, namely by 2 July 2026. I, the coroner, may extend the period if an appropriate application is made.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2026-0269
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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