Simon Delahunty
AI-generated concerns summaryThe coroner identified a lack of arrangements or guidance concerning the collection and disposal of unused end-of-life prescription medication.
Addressed to: Department of Health and Social Care
Source · Prevention of Future Deaths
Prevention of Future Deaths Reports
Browse 6,471 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
Contains public sector information licensed under the Open Government Licence v3.0.
Reports
Kelly Sutton
AI-generated concerns summaryThe coroner noted that non-crime information valuable to police for safeguarding domestic abuse victims is not available as a national resource, but remains limited to individual police areas.
Addressed to: Hertfordshire Constabulary
Sonny Parmar
AI-generated concerns summaryThe coroner noted the absence of a speed limitation on the road adjacent to the school, unlike other areas where traffic is slowed during school arrival and departure times.
Addressed to: Barnet Council
Lewis Francis
AI-generated concerns summaryThe coroner noted a lack of a mechanism for transferring individuals in police custody with serious charges to medium secure mental health facilities, and insufficient understanding of the needs of prisoners on the autistic spectrum.
Addressed to: Avon and Somerset Police; Cornwall Partnership NHS Foundation Trust; Cygnet Healthcare; Devon and Cornwall Police; Devon Partnership NHS Trust; Elysium Healthcare; Gloucestershire Police; Livewell Southwest; Prison and Probation service; Somerset Partnership NHS Foundation Trust; Wiltshire Police
John Gregory
AI-generated concerns summaryConcerns were raised about inconsistent staff standards and inadequate fluid intake management across two facilities, including inaccurate record-keeping and lack of observation when a patient's condition deteriorated. The report notes instances where staff did not adequately support the patient's hydration or comfort.
Addressed to: Care UK; University College Hospital
Daniel Moran
AI-generated concerns summaryThe coroner identified gaps in staff understanding of when to breach patient confidentiality for safety, clarification needed regarding roles in risk management and authorising leave, and better understanding of criteria for Mental Health Act detention.
Addressed to: Greater Manchester Mental Health NHS Trust
John Ashley
AI-generated concerns summaryConcerns included outdated care and treatment plans, a lack of regular psychiatric review for deteriorating mental health, and insufficient record-keeping. The coroner also noted gaps in handover procedures and communication between mental health teams and GPs.
Addressed to: Sussex Partnership NHS Foundation Trust
Rifky Grossberger
AI-generated concerns summaryThe coroner noted parents were unaware of the danger of metal blind cords and suggested better dissemination of safety information to new parents through healthcare professionals, postnatal leaflets, and the NHS website.
Addressed to: NHS England; Royal College of Nursing
Jason Pendlebury
AI-generated concerns summaryThe report identifies gaps in communication systems between Greater Manchester Police and North West Ambulance Service, and onward to GPs and mental health professionals. This resulted in incomplete information being available for risk assessments and appropriate referrals.
Addressed to: Greater Manchester Police; North West Ambulance Service
Billy Jenkins
AI-generated concerns summaryThe coroner identified that the Community Mental Health Nurse's assessment gathered insufficient information, leading to an inadequate multidisciplinary team review and a failure to properly assess the individual's mental health. The plan moving forward also lacked robustness.
Addressed to: ADAPT; Oxleas NHS Foundation
Anita Loi
AI-generated concerns summaryThe coroner noted a lack of action on managing a patient's leg wound despite multiple referrals, and community nursing teams did not engage with the GP to discuss the death. Concerns were also raised about the adequacy of referral policies and response protocols.
Addressed to: Central London Community Healthcare NHS Trust
Mitica Marin
AI-generated concerns summaryThe coroner identified delayed defibrillation due to a paramedic not activating the automatic mode on a defibrillator that defaults to manual, a factor in similar incidents. The report suggests defaulting to automatic mode or requiring a mode choice on startup could prevent future delays.
Addressed to: Department of Health and Social Care; London Ambulance Service; Physio-Control UK Ltd; Resuscitation Council; AACE
Robert Brown
AI-generated concerns summaryInformation about prisoners was not consistently available across different prison systems and to all relevant staff, leading the coroner to seek an update on the national development of a unified information system and its implementation timeline.
Addressed to: National Offender Management Service
Ian Weeks
AI-generated concerns summaryHealthcare staff did not adequately review Mr. Weeks' medical records upon admission to HMP Cardiff, leading to a failure to provide prescribed anti-depressants. The report identified a need for a 'red flag' system for suicide/self-harm and a clear process for reviewing all medical records upon prison admission.
Addressed to: Cardiff and Vale NHS Trust
Thelma Joyce
AI-generated concerns summaryThe report provided no specific details regarding the matters of concern, indicating a boilerplate introduction without further content.
Addressed to: NHS England
Shannon Quinn
AI-generated concerns summaryThe coroner identified inconsistent medical note sharing and a lack of a joint care plan between the Mental Health Trust and care home. Insufficient staff training and inadequate self-harm risk management, including observation adherence, were also noted.
Addressed to: Camino Healthcare; Care Quality Commission; Department of Health and Social Care; Solihull Mental Health Trust
Jose Orlando
AI-generated concerns summaryThe coroner identified a lack of hand holds to assist drivers entering trailers, potentially leading to misuse of metal props. Concerns were also raised about the absence of equipment like CO2 detectors for drivers to perform Border Force checks.
Addressed to: Tradomi S.L. Transporte
Susan Sterland
AI-generated concerns summaryThe coroner identified a concern that a patient deteriorating in the emergency department for 40 hours did not receive a senior doctor review, which could have led to earlier diagnosis. The report suggests the Trust consider expanding situations requiring mandatory senior review.
Addressed to: Kettering General Hospital NHS Foundation Trust
Darren Goddard
AI-generated concerns summaryMisleading patient information on TRUS elective surgery risks and premature post-operative discharge hindered early sepsis recognition. Subsequent delays occurred in triage escalation, timely treatment, and Critical Care admission.
Addressed to: Cwm Taf Morgannwg University Health Board
Roy Campbell
AI-generated concerns summaryThe coroner noted delays in implementing an electronic system to prevent detained patients from absconding, and that environmental checks to identify means for patients to leave a ward were not consistently carried out or enshrined in Trust policy with mandatory staff training.
Addressed to: Worcestershire Health and Care NHS Trust