Eugeniusz Malek
AI-generated concerns summaryThe coroner identified that scaffolding poles in areas where workers may fall, trip, or collide should be capped to enhance safety.
Addressed to: Health and Safety Executive
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
Henry Campbell-Byatt
AI-generated concerns summaryThe coroner raised concerns regarding the Peligoni Club's deep-water rescue capabilities, the provision of safety equipment for swimmers, and the adequacy of their watchtower manning and swimmer supervision systems.
Addressed to: Peligoni Club
Katherine Stamp
AI-generated concerns summaryThe coroner noted that clozapine's side effects, especially relating to smoking and pneumonia, are under-appreciated, and the BNF does not provide sufficient clarity to prescribers regarding these effects.
Addressed to: NHS England
Constance Robinson
AI-generated concerns summaryThe coroner noted that the limited operating hours of two Hyper Acute Stroke units in Greater Manchester lead to extended ambulance journeys and potential delays in urgent overnight treatment. Patients would benefit from 24-hour access and medical staff availability at all units.
Addressed to: Greater Manchester Stroke Operational Delivery Network; Salford Royal Hospital
Joshua Hoole
AI-generated concerns summaryThe coroner notes a persistent failure to address previously raised safety concerns, specifically regarding commanders' awareness and training on heat illness prevention guidance (JSP539). The report highlights that JSP539 is complex, inconsistent with other guidance, and lacks clarity for new fitness tests, alongside an absence of a system for sharing …
Addressed to: MOD
Mark Anderson
AI-generated concerns summaryThe safety of the general public, especially children and the elderly, is at risk from motorcyclists racing unfettered in Trelai Park.
Addressed to: Cardiff Council
Lewis Mendelson
AI-generated concerns summaryThe coroner identified backlogs preventing a DoLS and overdue annual care reviews due to staff shortages. Concerns were raised regarding insufficient IMCA involvement and best interests meetings during hospital care and end-of-life decisions for a patient with complex needs.
Addressed to: Department of Health and Social Care; Stockport Borough Council
Arnold Ward
AI-generated concerns summaryThe care home's forms did not adequately capture pressure ulcer deterioration, leading to a delay in recognition and escalation to the Tissue Viability Nursing team, and there was no system to chase up referrals.
Addressed to: Fernlea Nursing Home, Care Quality Commission, Stockport Clinical Commissioning Group
Clive Miles
AI-generated concerns summaryThe coroner raised concerns regarding the limited evidence of risk assessment when a patient, with a history of overdose, was moved from weekly to monthly prescriptions, resulting in them possessing a significantly increased quantity of medication.
Addressed to: Stockport Clinical Commissioning Group
Shirley Nightingale
AI-generated concerns summaryConcerns included a lack of clear systems for OGD management escalation, prioritisation, and follow-up. There was also no system to record rationale or obtain senior clinician agreement when departing from best practice timescales.
Addressed to: Tameside and Glossop Integrated Care NHS Trust
Terence James
AI-generated concerns summaryA patient's initial fall was not communicated to their GP or handed over to returning care staff. Additionally, a chiropodist's concerns about pain and a subsequent unwitnessed fall were not escalated for medical advice until later deterioration was observed.
Addressed to: Charing Healthcare
Joyce Marchant
AI-generated concerns summaryConcerns were raised regarding delays in a drainage procedure due to a shortage of interventional radiologists. The coroner also noted risks associated with using a postal system for GP information and a lack of clear communication between hospital centres.
Addressed to: Department of Health and Social Care; NHS England
Steven Marsland
AI-generated concerns summaryThe coroner identified a lack of family engagement and clear policy for community mental health teams to work with families post-discharge. There was also an insufficient handover between care teams, leading to no allocated community psychiatrist or follow-up, and a failure to maintain planned community contact.
Addressed to: Department of Health and Social Care; Pennine Care NHS Trust; Tameside and Glossop Clinical Commissioning Group
Iris Skinner
AI-generated concerns summaryAgency staff employed at Windmill Manor Care Home, and potentially across the Barchester Healthcare group, may be unfamiliar with the Barchester Healthcare Head Injury Policy.
Addressed to: Barchester Healthcare
Safoora Alam
AI-generated concerns summaryThe coroner identified inconsistent sharing of information and case notes between agencies, a lack of joint mental health and social care packages, and insufficient information gathering by social workers. The report also notes a slow process for urgent referrals for escalating mental health risks.
Addressed to: Black Country Partnership NHS Trust; Sandwell Council
Layla Dobson
AI-generated concerns summaryThe coroner identified a lack of a formal process for practitioners to determine appropriate mental health support pathways and insufficient flagging of self-harm/suicide risk on referral forms, noting that guidance could strengthen the systematic consideration of support pathways.
Addressed to: Leeds and York Partnership NHS Trust
Catherine McNamara
AI-generated concerns summaryThe coroner raised concerns regarding how the patient initially reached such high levels of prescribed opiates and the understanding of the impact these high doses had on her.
Addressed to: Trafford Clinical Commissioning Group
Peter Frosdick
AI-generated concerns summaryThe coroner noted inadequate mental health assessment and a lack of appropriate intervention due to a focus on alcohol and the patient's condition not fitting a psychiatric label. There was also insufficient inter-team awareness of referral criteria and professional curiosity.
Addressed to: Norfolk & Suffolk NHS Trust
Frances Gibb
AI-generated concerns summaryThe coroner identified serious deficiencies in the use of the National Early Warning Score (NEWS) system.
Addressed to: Brighton and Sussex University Hospital NHS Trust
Brenda Drew
AI-generated concerns summaryThe coroner noted a lack of formal GP review for repeat Oramorph prescriptions and raised concerns that pharmacists requested repeat medications from GPs without confirming the patient's wishes.
Addressed to: Royal Pharmaceutical Society