Prevention of Future Deaths Reports

Louis Rogers

AI-generated concerns summaryGaps were identified in medical education, research, and public information regarding febrile seizures. The coroner also noted insufficient guidance for paramedics and GPs on recognising and managing complex febrile seizures, alongside a lack of a coordinated referral pathway.

Addressed to: Joint Royal Colleges Ambulance Liaison Committee; National Institute for Health and Care Excellence; NHS England; Royal College of Emergency Medicine; Royal College of General Practice; Royal College of Paediatricians

4 responses identified · 6 indexed addressees. Read concerns and response evidence →

Aoife McAdam

AI-generated concerns summaryThe coroner noted that the patient was not advised to safely dispose of unused propranolol tablets when switching to a different medication. This left her in possession of a significant quantity of a potentially cardiotoxic drug she no longer needed.

Addressed to: Burton Croft Surgery

1 response identified · 1 indexed addressee. Read concerns and response evidence →

Kayleigh Burns

AI-generated concerns summaryThe report identifies a need to review the legal framework concerning Nitrous Oxide, given its increasing use by young persons and the associated risk of future deaths.

Addressed to: Ministry for Justice

0 responses identified · 1 indexed addressee. Read concerns and response evidence →

Gustavo Da Cruz, Mohit Dupar, Inthushan Sriskantharasa, Gurushanth Srithavarajah, Kenugen Saththiyanathan, Kobikanthan Saththiyanathan and Nitharsan Ravi

AI-generated concerns summaryThe coroner noted gaps in formal governance for beach safety, raising concerns about reliance on a voluntary structure. The report also describes the need to modernise safety regimes for diverse visitor groups and considers central government powers to restrict beach access.

Addressed to: Birnberg Peirce Solicitors; Department for Transport; Health and Safety Executive; Local Government Association; Maritime and Coastguard Agency; National Water Safety Forum; Rother District Council; Royal National Lifeboat Institution; Royal Society for the Prevention of Accidents; Sussex Police

5 responses identified · 10 indexed addressees. Read concerns and response evidence →

Jordan Clare

AI-generated concerns summaryThe coroner noted a long-standing gap in provision for vulnerable adults with complex needs who do not fit existing social services frameworks, resulting in a lack of a single point of contact and inconsistent support arrangements.

Addressed to: Department of Health and Social Care

1 response identified · 1 indexed addressee. Read concerns and response evidence →

Benjamin Nelson-Roux

AI-generated concerns summaryThe coroner noted that accommodation searches for a homeless 16-year-old were restricted to the county boundary, and raised concerns about the lack of residential substance misuse treatment facilities for those under 18.

Addressed to: Department of Health and Social Care; Harrogate Borough council; North Yorkshire County Council

2 responses identified · 3 indexed addressees. Read concerns and response evidence →

Richard Hill

AI-generated concerns summaryThe coroner identified a lack of specific guidance and educational material from the Rugby Football Union (RFU) for grassroots clubs regarding alcohol misuse and awareness. This is noted given evidence of excess alcohol consumption being an issue in male sports.

Addressed to: Rugby Football Union

1 response identified · 1 indexed addressee. Read concerns and response evidence →

Jade Revell

AI-generated concerns summaryThe SystemOne computer programme can obscure blood test results when minimised, lacking a scroll feature. This means abnormal results may be missed and unactioned, as the programme prevents them from being more visibly highlighted.

Addressed to: TPP LTD

1 response identified · 1 indexed addressee. Read concerns and response evidence →

Kenneth Adams

AI-generated concerns summaryThe MPDS protocol for assessing scalp lacerations does not adequately account for persistent bleeding, the impact of antiplatelet or anticoagulant medication, or the increasing risk of hypovolaemic shock, resulting in inappropriately low ambulance priority.

Addressed to: International Academics of Emergency Dispatch

3 responses identified · 1 indexed addressee. Read concerns and response evidence →

Ben Harrison

AI-generated concerns summaryThe coroner noted concerns that the Health Board's action plan following the death was not quickly addressed, with outstanding actions two years later. This delay indicates a lack of strategic direction for investigations and learning.

Addressed to: Betsi Cadwaladr University Health Board

0 responses identified · 1 indexed addressee. Read concerns and response evidence →

Jennifer Davies

AI-generated concerns summaryThe coroner raises concerns that delivery van drivers (under 3.5 tonnes) are not subject to current Working Time Regulations, allowing long shifts without legally mandated breaks, which poses a risk to public safety.

Addressed to: Department for Transport

1 response identified · 1 indexed addressee. Read concerns and response evidence →

Nicola Norman

AI-generated concerns summaryThe coroner noted that SPA contacts were not routinely discussed with a supervising clinician or passed to a suitably qualified clinician for mental health assessment, especially when suicidality was raised. Additionally, these contacts were not routinely notified to the patient's GP or other mental health services.

Addressed to: Central and North West London NHS Foundation Trust

0 responses identified · 1 indexed addressee. Read concerns and response evidence →

Benjamin Teague

AI-generated concerns summaryThe coroner noted the A5 road between Pottersbury and Paulesbury was in a very poor state with potholes, which deteriorated shortly after a repair following a road traffic collision.

Addressed to: National Highways

1 response identified · 1 indexed addressee. Read concerns and response evidence →

Rachael Walker

AI-generated concerns summaryThe coroner notes a lack of robust processes for timely updating of clinical policies and guidance, including national pregnancy guidance, and for ensuring essential equipment is obtained and located. Some critical procedural changes were only addressed very recently.

Addressed to: University Hospitals of Derby and Burton NHS FT

1 response identified · 1 indexed addressee. Read concerns and response evidence →

Jai Singh

AI-generated concerns summaryThe coroner raises concerns about the absence of a psychiatrist in the mental health team's multi-disciplinary meetings and the lack of ongoing risk assessment documentation for patients with mental illness in HMP Birmingham's SystemOne records.

Addressed to: Birmingham and Solihull Mental Health FoundationTrust, NHS England, and Phoenix Partnership Ltd

3 responses identified · 1 indexed addressee. Read concerns and response evidence →

John Ibboston

Addressed to: Health & Safety Executives; Road Transport Industry Training Board; Associate of Pallet Networks; Timber Packaging and Pallet Confederation

0 responses identified · 4 indexed addressees. Read concerns and response evidence →

Brian Harfield

AI-generated concerns summaryThe coroner highlights the lack of compulsory sprinkler or fire safety provisions for individuals in extra care facilities or retirement housing receiving care at home. This group's declining health and mobility increase their fire risk, a gap not addressed by current consultations.

Addressed to: Ministry of Housing, Communities & Local Government

1 response identified · 1 indexed addressee. Read concerns and response evidence →

Tarik Drakes

AI-generated concerns summaryInsufficient staffing and monitoring at Dorset Lodge permits unmonitored entry by non-residents and drug use within the premises. Additional concerns include agency staff not conducting key worker sessions and a non-functional out-of-hours emergency contact.

Addressed to: Bournemouth Churches Housing Association (BCHA)

1 response identified · 1 indexed addressee. Read concerns and response evidence →

Lugh Baker

AI-generated concerns summaryThe coroner noted inconsistent resident monitoring and a lack of documented adherence to new monitoring systems. Concerns were also raised about the insufficiently prompt review of new resident care plans and the absence of a policy for managing residents with unusual presentations.

Addressed to: Bowden Derra Park Ltd

1 response identified · 1 indexed addressee. Read concerns and response evidence →

Charlotte Comer

AI-generated concerns summaryThe coroner noted the Trust's inability to understand how inconsistent care coordinator provision resulted from staff instability and high workloads. Additionally, there was no robust system to prevent senior clinicians from unilaterally overriding Multi-Disciplinary Team decisions.

Addressed to: Herefordshire & Worcestershire Health and Care NHS Trust

1 response identified · 1 indexed addressee. Read concerns and response evidence →