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 188 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
19 Mar 2019	Mark Parry 2019-0094 · Heath Westerman A critical lack of published Health and Safety Executive guidelines for mechanics working with Heavy Goods Vehicle air suspensions exists. This absence …	North West Cheshire	Health and Safety Executive	1/1
14 Mar 2019	Katharine Dowling 2019-0089 · Alan Moore Critical gaps exist in national guidance and consistent support for autistic patients with co-existing mental health conditions. Limited ASD-appropriate environments and inadequate, …	North West Cheshire	NHS England	1/1
13 Mar 2019	Tamsin Grundy 2019-0088 · Jacqueline Lake A lack of continuity of care, with the patient seeing many different staff members, adversely impacted her mental health. Despite being noted, …	East of England Norfolk	Norfolk & Suffolk NHS Trust	1/1
11 Mar 2019	David Mobsby 2019-0087 · Veronica Hamilton-Deeley Inadequate health and safety guidance failed to address work at height risks, leading to an untrained and unsupervised employee performing dangerous tasks …	South East Brighton and Hove	Blatchington Mill School Brighton and Hove City Council Department of Education	0/3
25 Mar 2019	Nora Bruton 2019-0090 · Adam Hodson Inadequate dissemination of substance abuse risk assessment training and a failed review of crisis call communication protocols led to safety gaps. The …	West Midlands Birmingham and Solihull	Birmingham & Solihull Mental Heath …	1/1
25 Mar 2019	Christopher Gibbs 2019-0100 · Richard Middleton The A338, a 10-mile arterial route with consistent speed limits and no exits, presents inherent risks due to its design of straight …	South West Dorset	Bournemouth Borough Council Dorset County Council	1/2
25 Feb 2019	Steven Key 2019-0102 · Robert Chapman Inadequate low fencing at the railway line allowed easy access, posing a significant risk of death or injury from high-speed trains to …	North West Cumbria	Network Rail	1/1
22 Mar 2019	Brian Havard 2019-0101 · Yvonne Blake Critical ambulance records were not accessed or read by doctors, and senior medical staff lacked professional curiosity. Poor record-keeping and an inadequate …	East of England Norfolk	Norfolk and Norwich University Hospital	0/1
27 Mar 2019	Justin Brown 2019-0103 · Jacqueline Devonish Hospital discharge processes failed to ensure confirmed addiction support. A lack of agreed protocols and collaboration with drug services meant referrals were …	East of England Suffolk	Suffolk County Council	0/1
20 Mar 2019	Christopher Bevan 2019-0104 · Tim Holloway Ladders were used unsafely on a slippery surface, unfooted, and improperly secured. This highlights a risk of unsafe work practices leading to …	North West Blackpool & Fylde	Holloway Assistant Coroner for Blackpool … Iam Tim	0/2
28 Mar 2019	Wayne Rodgers 2019-0105 · Caroline Sumeray Ambulance services are overstretched, and major event safety planning is insufficient. Deficiencies include lack of on-site medical provision, inadequate crisis management, and …	South East Isle of Wight	Cowes Week Limited Emergency Preparedness, Resilience and Response Resilience and Response, Isle of … Jubilee Stores	1/5
29 Mar 2019	Colin Bailey 2019-0106 · Christopher Murray National guidelines on head injury assessment do not universally recommend CT scans for patients on non-warfarin anticoagulants, despite clinical consensus for their …	North West Manchester (South)	N.I.C.E	0/1
29 Mar 2019	Ann Corfield 2019-0107 · Anthony Mazzag Inadequate patient handover between hospitals led to critical medication information loss. Poor fluid balance chart completion, delayed prophylactic anticoagulation, and mental health …	North West Manchester (City)	Greater Manchester Mental Health NHS … Pennine Acute Hospitals NHS Trust	0/2
22 Mar 2019	Bram Radcliffe 2019-0110 · Martin Fleming Dangerous, substandard fireplace surround installations are unregulated as they are not deemed "building work." There is no British Standard for fixing these …	Yorkshire and the Humber West Yorjshire (West)	Ministry of Housing, Communities and … Stone Federation of GB	0/2
7 Mar 2019	Matthew Bilby 2019-0112 · Timothy Brennard A dangerous and confusing staggered junction, identified as an accident blackspot with multiple fatalities, poses an ongoing risk to road users due …	East Midlands Lincolnshire	Department for Transport Lincolnshire County Council	2/2
1 Apr 2019	Andrew Clegg 2019-0108 · Nicholas Rheinberg Care homes are rarely designed with water safety in mind, and CQC inspectors lack sufficient training to identify legionella risks in water …	South West Wilshire and Swindon	Care Quality Commission Royal Institute of British Architects	1/2
11 Mar 2019	Terence Bradfield 2019-0086 · Deborah Archer Failures in steroid administration, prescription, and staff training on steroid management were identified. There was also a lack of policy on steroid …	South West Plymouth Torbay and South Devon	University Hospitals Plymouth NHS Trust	0/1
7 Mar 2019	Kristopher McDowell 2019-0083 · John Gittins The report raises concerns about the wide spacing on the aqueduct parapet, posing a fall risk, and the subjective nature of the …	Wales North Wales (East and Central)	Canal and River Trust	1/1
7 Mar 2019	Chand Ali 2019-0085 · Alison Hewitt Cyclizine, cautioned for severe heart failure, is routinely administered without individual risk assessment or monitoring of adverse outcomes. There has been no …		Barts Health NHS Trust	1/1
8 Mar 2019	John Richardson 2019-0084 · Penelope Schofield Confusion among staff regarding voluntary patients' leave status highlighted the absence of a specific leave policy for voluntary patients, unlike those sectioned …	South East West Sussex	Sussex NHS Trust	1/1