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 |
|---|---|---|
| 12 Apr 2019 |
Emma Butler
2019-0133A · Crispin Butler
Inadequate control of plastic cutlery on the ward and inconsistent search procedures for patients returning from leave created self-harm risks, compounded by …
|
1/1 |
| 15 Apr 2019 |
Nyall Brown
2019-0134A · Jacqueline Lake
Patient care records were not reviewed before assessment, meaning full history and risks were not considered, a recurring issue despite existing staff …
|
1/1 |
| 12 Apr 2019 |
Duncan Tomlin
2019-0135 · Elisabeth Bussey-Jones
Police training inadequately emphasizes the heightened risks of prone restraint with multiple breathing-affecting factors. Officers may prioritize quick removal over adequately assessing …
|
2/3 |
| 17 Apr 2019 |
Patrick Kelly
2019-0128A · Abigail Combes
Care centres fail to prioritise dental hygiene and services, leading to potentially worsened conditions and lacking policies for managing missed appointments or …
|
1/1 |
| 4 Apr 2019 |
Lesley Armstrong
2019-0136 · Tony Brown
Northumbria Police failed to communicate the discontinuation of an investigation, hindering the employer's ability to inform the employee and the Safeguarding Board …
|
1/1 |
| 15 Apr 2019 |
Jennifer Lewis
2019-0003 · Roger Hatch
There was a failure to coordinate care between mental and physical health doctors, resulting in unsuitable and inadequate care for the patient's …
|
1/1 |
| 15 Apr 2019 |
Shaun Neal
2019-0009 · James Thompson
The absence of double solid white lines at a collision site, despite expert opinion they could prevent dangerous manoeuvres, raises concerns about …
|
1/1 |
| 26 Apr 2019 |
William Hignett
2019-0138 · Alan Moore
Safety concerns include hazardous junction configuration, insufficient street lighting, vegetation obstructing visibility, and an inappropriate speed limit.
|
0/1 |
| 29 Apr 2019 |
Georgia Nelson
2019-0140 · Fiona Wilcox
There is a lack of suitable housing specifically for young patients with severe and enduring mental health issues.
|
2/2 |
| 30 Apr 2019 |
Mark Hinton
2019-0142 · John Ellery
Critical patient information regarding a potential blood clot was not recorded or passed on, and a requested D-Dimer test result was not …
|
1/1 |
| 10 Apr 2019 |
Christopher Innes
2019-0124 · Bina Patel
An unmarked bus stop on a 50mph road without pedestrian facilities created a hazard for alighting passengers, exacerbated by overgrown vegetation and …
|
1/2 |
| 29 Apr 2019 |
Alfonso Sinclair
2019-0141 · Fiona Wilcox
A distressed individual's overtly odd and illegal behaviour at a tube station went unnoticed and unchallenged by staff, despite CCTV, due to …
|
1/1 |
| 22 Mar 2019 |
Mark Kubiak
2019-0098 · Tom Osborne
The patient transfer checklist failed to require essential oxygen supply checks and tug tests. This systemic flaw meant oxygen flow failure went …
|
0/1 |
| 18 Mar 2019 |
Frederick Brooker
2019-0097 · Nadia Persaud
The care home failed to implement adequate falls prevention, lacking care plans despite identified risks. Multiple falls were not properly investigated or …
|
1/1 |
| 21 Feb 2019 |
Terrence Smith
2019-0095 · Richard Travers
The ambulance call handling system failed to recognize Excitatory Delirium, conflicting guidance for call handlers caused confusion, and training packages contained potentially …
|
0/7 |
| 20 Mar 2019 |
Pamela Sunter
2019-0096 · Christopher Dorries
Outdated "two week wait" forms remain on the system, causing confusion due to insufficient priority given to their removal. This hinders efficient …
|
0/1 |
| 19 Mar 2019 |
Mohammed Ahmed
2019-0093 · Jacqueline Devonish
Combined use of Olanzapine and Spice caused a fatal allergic reaction, yet Olanzapine continued to be prescribed. Clinicians may lack national awareness …
|
1/2 |
| 19 Mar 2019 |
Graham Tailby
2019-0092 · John Hobson
No specific concerns were detailed in the provided text.
|
1/1 |
| 12 Mar 2019 |
Marjorie Gartside
2019-0091 · Catherine McKenna
The hospital provided inaccurate discharge information and had unsafe discharge processes, leading to a lack of handover and critical medication not being …
|
1/1 |
| 18 Mar 2019 |
Ellie Long
2019-0090A · Jacqueline Lake
The coroner highlights failures in record keeping and communication with external agencies, specifically that records were not properly recorded, handwritten notes were …
|
1/1 |