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 190 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
22 Feb 2019	Doreen Fell 2019-0109 · Paul O’Donnell The national speed limit and lack of street lighting on a trunk road through a village created hazardous pedestrian crossing conditions, especially …	North West Cumbria	Highways England	1/1
3 Apr 2019	Ronald Lowe 2019-0113 · Emma Brown A hospital's system for ensuring radiographers had read and signed standard operating procedures was not robust, increasing the risk of dangerous practice …	West Midlands Birmingham and Solihull	University Hospitals Birmingham NHS Trust	1/1
3 Apr 2019	Terence Thornton 2019-0114 · Andrew Cox Severe staffing shortages of radiology clinicians at Derriford Hospital are creating dangerous work pressures and increasing the risk of medical errors and …	South West Plymouth Torbay and South Devon	Derriford Hospital University Hospitals Plymouth NHS Trust	1/2
19 Feb 2019	Janice Keelan 2019-0057 · Nigel Meadows No specific concerns were detailed in the provided text.	North West Manchester (City)	Manchester City Council Manchester Mental Health NHS Trust	1/2
14 Jan 2019	Dane Pearson 2019-0056 · Alison Mutch Police issued a CAWN without proper evidence, rationale, or risk assessment for a vulnerable person, and failed to communicate the decision to …	North West Manchester (South)	Greater Manchester Police Home Office	1/2
15 Feb 2019	Dwayne Thompson 2019-0055 · Alison Mutch Reservoir safety was compromised by a regularly damaged fence and warning signs that failed to consider the needs and understanding of individuals …	North West Manchester (South)	Health and Safety Executive Royal Society of Prevention of …	1/2
20 Feb 2019	Malcolm Rathmell 2019-0059 · Jane Gillespie Incorrect warfarin prescribing went unidentified by multiple professionals, an anti-coagulation chart was mislabeled, and a lack of ward-based pharmacy review, with proposed …	East Midlands Nottinghamshire	Nottinghamshire University Hospitals NHS Trust	2/1
12 Feb 2019	Bryan Gray 2019-0054 · Rosemary Baxter There was an absence of window restrictors on multiple windows within the building, posing an ongoing fall risk for residents, despite one …	Yorkshire and the Humber East Riding and Hull	Crossing Project	0/1
14 Feb 2019	John Mellor 2019-0053 · Nicholas Flanagan The report identifies a systematic failure to ensure blood tests are conducted for individuals under specialist care for renal failure and a …	North West Manchester (North)	Northern Care Alliance NHS Group Oldham Care Commissioning Group Pennine Care NHS Trust St Chads Medical Practice	1/4
14 Feb 2019	Douglas Minns 2019-0052 · Tom Osborne The coroner raises concerns about the withdrawal of a falls service, which provided home visits to assist those who had fallen, assessing …	South East Milton Keynes	Milton Keynes Clinical Commissioning Group	1/1
14 Feb 2019	John Scott 2019-0051 · Veronica Hamilton-Deeley No specific concerns text was provided for summarization.	South East Brighton and Hove	NHS Pathways South East Coast Ambulance Service	2/2
24 Feb 2019	Polly Drew 2019-0073 · Elizabeth Didcock The recruitment process for a doctor with access to anaesthetic drugs and significant responsibility was completely inadequate, leading to her working alone …	East Midlands Nottinghamshire	Central Medical Services	0/1
25 Feb 2019	Brenda Gowan 2019-0064 · Nadia Persaud Inadequate discharge planning for a stroke patient included insufficient social care, disregarded family concerns, unassessed falls risk, lack of community support, and …	London London (East)	Royal London Hospital	1/1
22 Feb 2019	Jeremy Sutch 2019-0065 · Nigel Parsley Medical evacuation was severely delayed by crew unfamiliarity with a wheelchair extraction stretcher, its incompatibility with ship equipment, and lack of evacuation …	East of England Suffolk	International Maritime Organisation Vantage Drilling Company	1/2
26 Feb 2019	Christopher Moss 2019-0066 · Andrew Haigh Concerns exist regarding the availability of appropriate equipment, specifically a hooligan bar, for dealing with cell door barricade incidents in prisons, potentially …	West Midlands Staffordshire South	MOJ	0/1
26 Feb 2019	John Thorp 2019-0067 · Catherine Wood Inconsistent prescription practices for TED stockings, coupled with inadequate documentation for nursing administration, increased the risk of thromboembolic formation due to stockings …	London London (West)	London North West University NHS …	1/1
25 Feb 2019	John Pearce 2019-0068 · Edwin Buckett The District Nursing Team failed to urgently refer a patient with a severely worsening knee wound, visible over two months of regular …	London London Inner (North)	Central and North West London …	1/1
27 Feb 2019	Peter Garvin 2019-0069 · Fiona Wilcox Poor communication between the CMHT and GP, a lack of local mental health beds, and a policy to discharge NHS patients seeking …	London London Inner (West)	Central and North West London … NHS England	1/2
20 Feb 2019	Kevin Miles 2019-0058 · Dianne Hockling The diver medical certification process is flawed as it doesn't require GP records, enabling misreporting of health issues and risking divers' and …	East Midlands Leicester City and South Leicestershire	Health and Safety Executive Inspector of Diving	1/2
21 Feb 2019	Robert Chandler 2019-0060 · Jacqueline Lake Defective lifting equipment, inconsistent daily checks, incomplete records, and significant delays in implementing internal investigation recommendations posed risks to patient safety and …	East of England Norfolk	East of England Ambulance Service	1/1