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.

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6,386 reports · Page 186 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
15 Jan 2019	Catherine Horton 2019-0143 · Sarah Ormond-Walshe Multiple failures in a missing persons investigation, including incorrect closure due to severe understaffing and high workload in the police missing persons …	London London (South)	Metropolitan Police Service	1/1
20 Jun 2019	Geoff Gray 2019-0216 · HH Peter Rock QC There is a lack of specific guidance for post-mortem examinations in firearms deaths, especially for children. Assumptions of suicide risk cursory investigations, …	South East Surrey	Chief Coroner of England and … President of the Royal College …	1/2
9 Apr 2019	Anthony Buckingham 2019-0123 · Daniel Sharpstone The death could have been prevented by daily mental health team visits, formal mental health act assessment, next of kin involvement, and …	East of England Suffolk	Norfolk and Suffolk NHS Trust	1/1
5 Apr 2019	Yong Hong 2019-0130 · Sonia Hayes The observation regime advised by the GP was not implemented, and no interpreter was sought to assist with assessment of his needs. …	London London (South)	Bondcare, Clarendon Care Home Care Quality Commission Croydon County Council Thornton Heath Medical Practice	0/4
2 Apr 2019	Tarek Chowdhury 2019-0131 · Richard Furniss There is a failure to share critical prisoner information between HMPPS and immigration detention facilities, alongside issues with the SystmOne records system's …	London London (West)	HM Prison & Probation Service Home Office NHS England	0/3
5 Apr 2019	Alice Dixon 2019-0132 · Simon Wickens A vulnerable patient received inadequate assistance during the consent process for a scan, resulting in an unclear consent form and unaddressed communication/hearing …	South East Surrey	Ashford and St Peter’s Hospitals …	0/1
18 Apr 2019	Roger Neaves 2019-0130-wp26624 · Ian Arrow Confirmation is needed that the recommendations from the Hospital Trust's Root Cause Analysis following the patient's death have been fully implemented.	South West Plymouth Torbay and South Devon	University Hospitals Plymouth NHS Trust	0/1
17 Apr 2019	Nathan Cooke 2019-0125 · Caroline Sumeray There's no robust system to manage patients prescribed medication requiring regular monitoring, potentially endangering welfare if they don't attend reviews.	South East Isle of Wight	Hampshire and Isle of Wight …	0/1
17 Apr 2019	Megan Jones 2019-0126 · Caroline Sumeray A lack of formal policy or protocol for GP surgeries to monitor patients prescribed Clozapine, specifically regarding QTc recording and when exceeding …	South East Isle of Wight	Hampshire and Isle of Wight …	0/1
17 Apr 2019	June Russell 2019-0128 · Heidi Connor The junction has a persistently high injury collision rate, requiring urgent improvements to signage, traffic lights, and line of sight, with existing …	South East Berkshire	Slough Borough Council	1/1
17 Apr 2019	Brian Goodman 2019-0129A · Sarah Bourke A known ligature point in the patient's room was not addressed, and similar hazardous door closing mechanisms remain in use in other …	London London Inner (North)	One Hosing Group	1/1
25 Apr 2019	Michael Davies 2019-0134 · Jonathan Layton The evidence revealed general concerns indicating a risk of future deaths without specifying particular issues.	Wales Camarthenshire and Pembrokeshire	Welsh Ambulance Service NHS Trust	1/1
18 Apr 2019	Graham Jones 2019-0131A · Katy Skerrett Concerns include insufficient falls prevention measures, inadequate understanding of post-fall protocols and medication review, and poor handover of patient safety information between …	South West Gloucestershire	Gloucestershire Hospitals NHS Trust	1/1
16 Apr 2019	Jonathan Yates 2019-0132A · Katy Skerrett The nutritional status of patients, particularly those nil by mouth, is not effectively communicated to staff during hospital admissions.	South West Gloucestershire	Gloucestershire Hospitals NHS Trust	1/1
24 Apr 2019	Deborah Hopkinson 2019-0133 · Matthew Cox Frequent equipment failures and significant delays in specialist consultant involvement due to lack of expertise and communication issues severely impacted patient diagnosis …	North West Manchester (North)	Pennine Acute Hospitals NHS Trust	1/1
2 Apr 2019	Elsa Reid 2019-0139 · Zafar Siddique Inadequate communication between the hospital and occupational therapist delayed mobility intervention, leading to a minimal exercise regime and increased risk of patient …	West Midlands Black Country	New Cross Hospital NHS Trust Wolverhampton City Council	0/2
24 Apr 2019	Ioannis Avgousti 2019-0135A · Veronica Hamilton-Deeley The evidence revealed general concerns indicating a risk of future deaths without specifying particular issues.	South East Brighton and Hove	Brighton and Sussex University Hospitals …	1/1
29 Apr 2019	Steffan Kuenzel 2019-0002 · Sarah Bourke The patient received insufficient specific guidance on safe alcohol reduction methods and was unaware of critical alcohol withdrawal symptoms beyond seizures requiring …	London London Inner (North)	Barts Health NHS Trust	1/1
25 Apr 2019	Mildred Clark 2019-0127 · Sonia Hayes A paramedic was inappropriately instructed to perform an untrained hernia reduction, causing pain, when the patient should have been transferred to hospital …	South East Kent (North-East)	East Kent University Hospitals NHS England South East Coast Ambulance Service	0/3
23 Apr 2019	Kerry Hunter 2019-0137 · Nigel Parsley The proposed in-house Borderline Personality Disorder service access pathway may inadvertently exclude patients due to their condition's characteristics, like avoidance and previous …	East of England Suffolk	Norfolk & Suffolk NHS Trust	2/1