Source · Prevention of Future Deaths
Prevention of Future Deaths Reports
Browse 6,386 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
| Date | Report | Responses identified |
|---|---|---|
| 17 May 2019 |
Barry Fullarton
2019-0159 · Andre Rebello
Mental health assessments must account for the diurnal nature of reactive depressive illness, as an assessment at a good mood time may …
|
1/1 |
| 17 May 2019 |
Jenson Francis
2019-0158 · David Regan
A dysfunctional team exhibited unclear clinical leadership, poor CTG interpretation and communication, inadequate record-keeping, and insufficient staffing, with junior staff unable to …
|
1/1 |
| 17 May 2019 |
Mellin Beard
2019-0157 · Chris Morris
The Trust experiences persistent delays in timely referrals for community nursing post-discharge and relies significantly on agency nurses, impacting continuity of patient …
|
1/2 |
| 8 Apr 2019 |
Ronald Clark
2019-0151 · David Clark
Stents supplied in identical packaging with only small labels pose a risk of using incorrect sizes during medical procedures.
|
1/2 |
| 14 May 2019 |
Anthony Walker
2019-0152 · David Clark
Specific concerns were unavailable as the text referenced an attached sheet.
|
3/4 |
| 15 May 2019 |
Marion Prance
2019-0154 · Rachel Knight
Paramedics lacked awareness and training regarding the dangers of administering anticoagulants like Rivaroxaban to elderly fall patients with head injuries, requiring enhanced …
|
1/1 |
| 16 May 2019 |
Benjamin Murray
2019-0155 · Maria Voisin
Low rates of mental health disclosure in university applications and the absence of formal investigation reports following student deaths indicate systemic gaps …
|
3/2 |
| 16 May 2019 |
Kevin McDonald
2019-0156 · Geraint Williams
Discharge paperwork from the clinical decision-making unit lacks clarity regarding follow-up advice, leaving patients uncertain about their post-discharge care and increasing risks.
|
0/1 |
| 12 Jul 2019 |
David Jukes
2019-0329 · Emma Brown
Critical information was withheld from mental health assessors in custody, and communication breakdowns meant existing mental health teams failed to assess the …
|
5/5 |
| 24 Jul 2019 |
Maureen Woods
2019-0497 · Laurinda Bower
National ambulance response times for category 2 calls, including potential cardiac events, are too slow, and local attempts to mitigate this through …
|
0/2 |
| 21 Jun 2019 |
Michael Folley
2019-0230 · Karen Harrold
The outdated Person Escort Record (PER) system limits access to crucial past self-harm risk data. Gaps in staff training and inconsistent transfer …
|
2/5 |
| 28 Jun 2019 |
Heather Birchall
2019-0223 · David Ridley
Healthcare professionals assessing detained persons lack full access to mental health records, especially out-of-hours, due to confidentiality issues, hindering informed decisions for …
|
0/1 |
| 8 Apr 2019 |
Tina Tait
2019-0129 · Alan Wilson
Persistent issues with poor and illegible clinical record-keeping within the hospital compromise incident reviews and patient care, impeding crucial learning from deaths.
|
0/1 |
| 13 Mar 2019 |
Mohammed Hussain
2019-0122 · Emma Whitting
Mental health assessments were flawed due to staff misunderstanding training and poor information sharing between staff and care providers. Despite further training, …
|
1/1 |
| 10 Apr 2019 |
David Dooley
2019-0127A · Gilva Tisshaw
Police officers' lack of knowledge regarding seafront lifeline locations caused critical delays, and public awareness of sea dangers, particularly under the influence, …
|
1/1 |
| 9 Apr 2019 |
Freda Mason
2019-0126A · Simon Jones
The council's reactive bus shelter maintenance system, relying only on public complaints, lacks a proactive inspection regime, leading to delays in identifying …
|
1/2 |
| 2 Apr 2019 |
Stuart Clark
2019-0125A · Philip Spinney
A patient's disclosure of suicide risk was not properly assessed or escalated to senior staff, and relevant information was not immediately available …
|
1/1 |
| 18 Mar 2019 |
Peter Knight
2019-0219 · Jacqueline Lake
The Trust significantly delayed completing and implementing a crucial policy for transferring oxygen-dependent patients. New documentation was produced, but trials had not …
|
1/1 |
| 26 Jun 2019 |
Colin Cameron
2019-0218 · Katy Skerrett
Signallers lacked instructions for extracting information from users, and authorities had not sufficiently considered closing the railway crossing.
|
1/1 |
| 27 Jun 2019 |
Frank Stockton
2019-0466 · Tim Holloway
Clinicians may lack awareness of the fatal risks of epistaxis, particularly in vulnerable patients on oxygen or Warfarin, and failed to recognize …
|
0/2 |