After the inquest, the coroner produced an official document in January 2014, known as an "action to prevent future deaths" report – a process introduced in July 2013 – which was sent to the CQC.
The South Staffordshire coroner, Andrew Haigh, said he would write a "prevention of future deaths report" to the National Offender Management Service to recommend the implementation of a clear policy on transfer which ensured that a prisoner's particular vulnerabilities were considered.
No date has been fixed for the full hearing as the coroner said a separate independent inquiry could have an impact on his responsibility to compile a prevention of future deaths report.
In this issue of EHP, the authors of a new study of SIDS deaths report that hotter outdoor temperatures also may be a risk factor.
However, the authors of the maternal deaths report noted the uncertainty around their estimates; the number of women in each ethnic group who died was fewer than 10 in all groups except white and black African.
The last UK confidential enquiry into maternal deaths report [ 35] reported that 3 of the 5 deaths during the first trimester were of women from an African-Caribbean origin.
