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 189 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
22 Feb 2019	Gabriele Kreichgauer 2019-0082 · Philip Barlow The patient was discharged without antibiotics due to missed checks, and an incorrect diagnosis from an internet resource led to ineffective treatment. …	London London Inner (South)	Barts Health NHS Trust	0/1
26 Feb 2019	Lyn Morgan 2019-0080 · Aled Gruffydd A road barrier failed to redirect a lorry as designed, causing it to re-enter the carriageway. Given the heavy vehicle use, there's …	Wales Swansea Neath & Port Talbot	Welsh Government	1/1
26 Feb 2019	Danyon Chesters 2019-0079 · Alison Mutch Significant delays in accessing NHS mental health services led to fragmented private care, lack of information sharing between professionals, and private therapists …	North West Manchester (South)	Department of Health and Social …	1/1
1 Mar 2019	Jack May 2019-0078 · Rachel Knight Inadequate university mental health services, characterized by long waits and limited appointments, combined with patchy, poorly trained pastoral support from personal tutors, …	Wales South Wales Central	Cardiff University	1/1
26 Feb 2019	Kathleen McGeary 2019-0081 · Stephanie Haskey The coroner notes a lack of comprehensive assessment, investigation, diagnosis, and treatment for the vulnerable patient before discharge, unclear responsibility for discharge …	East Midlands Nottinghamshire	Doncaster and Bassetlaw Teaching Hospitals …	1/1
1 Feb 2019	Stephen Harte 2019-0077 · James Bennett Drugs too easily entered the secure mental health unit due to unchecked external food orders, inadequate searches of residents returning from leave, …	West Midlands Birmingham and Solihull	Birmingham and Solihull Clinical Commissioning … Care Quality Commission	2/2
27 Feb 2019	Hoshi Naylor 2019-0076 · Oliver Longstaff The absence of facilitated pedestrian crossing points and sparse crossing infrastructure in a busy area, combined with poor street lighting, creates a …	Yorkshire and the Humber West Yorkshire (East)	Leeds City Council	1/1
27 Feb 2019	Shane Gray 2019-0075 · Penelope Schofield Inadequate, text-only signage and a lack of physical barriers create a significant drowning risk in an area of the lake frequented by …	South East West Sussex	Park Holiday UK Limited	1/1
27 Feb 2019	Kelvin Speakman 2019-0074 · Geraint Williams The ACCT process at HMP Hewell suffered from inadequate documentation, poor healthcare input, and inconsistent staff communication, leading to incomplete patient information. …	West Midlands Worcestershire	HMP Hewell HM Prison Service	1/2
26 Feb 2019	Nathan Mooney 2019-0072 · Chris Morris The report indicates general concerns were raised during the inquest, but specific details regarding the identified risks were not provided in the …	North West Manchester (South)	Department of Health and Social …	1/1
26 Feb 2019	Geoffrey Jackson 2019-0071 · Chris Morris The report indicates general concerns were raised during the inquest, but specific details regarding the identified risks were not provided in the …	North West Manchester (South)	Manchester University Hospitals NHS Trust	0/1
27 Feb 2019	Theresa Feehan 2019-0070 · Fiona Wilcox The practice's medication review system was inadequate, with outdated patient records and poor correlation between problem lists and prescribed drugs. This led …	London London Inner (West)	Care Quality Commission Lisson Grove Health Centre	1/2
3 Apr 2019	Aryan Akhgar 2019-0115 · Stephen Eccleston A critical gap exists in urgent mental health services for 16 and 17-year-olds in Sheffield, with necessary additional resources for CAMHS lacking …	Yorkshire and the Humber South Yorkshire (West)	Sheffield Children’s Hospital Sheffield Clinical Commissioning Group	2/2
5 Apr 2019	Raymond Knight 2019-0120 · Caroline Beasley-Murray Police station CCTV cameras do not cover individual holding cells, creating a critical gap in monitoring and photographic records of prisoners.	East of England Essex	Essex Police	0/1
21 Jan 2019	Alfred Howell 2019-0116 · John Hobson Concerns related to the process of identifying and responding to a patient's deteriorating lung condition, noted through serial CT scans and MDT …	Yorkshire and the Humber West Yorkshire (East)	Mid Yorkshire Hospitals NHS Trust	1/1
1 Apr 2019	Alexander Green 2019-0117 · Maria Voisin Ineffective trust-wide handovers and a failure to challenge assumptions led to critical delays in diagnosing a head injury due to bias towards …	South West Avon	Royal United Hospital	1/1
1 Apr 2019	Marcie Tadman 2019-0118 · Maria Voisin No specific matters of concern were detailed in the provided text.	South West Avon	Banes Clinical Commissioning Group Royal United Hospital, Bath	1/2
4 Apr 2019	Julia Peto 2019-0119 · Christopher Williams Many two-stage pedestrian crossings nationally may lack louvres to prevent 'see-through' confusion from green signals and proper road markings to warn pedestrians …	London London Inner (South)	Department for Transport	1/1
5 Apr 2019	Jennifer Handy 2019-0121 · Rachael Knight The inability to trace a doctor who left the UK after treating a patient compromised the investigation and prevented the clinician from …	Wales South Wales Central	Cwm Taf Health Board General Medical Council	2/2
27 Mar 2019	Donna Williamson 2019-0111 · Andrew Harris The report identifies failures in repairing and securing a door, informing the victim of the suspect's release on bail, and the MARAC …	London London Inner (South)	Department of Health and Social … Home Office Local Government Association London Borough of Lewisham	1/5