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 |
|---|---|---|
| 21 Feb 2019 |
Jason Gregory
2019-0061 · Grahame Short
Citywatch radio reports of serious disturbances are not being relayed to police in a timely manner, risking delayed emergency response and a …
|
0/2 |
| 25 Jan 2019 |
David Squire
2019-0062 · Emma Serrano
Smoke-free hospital guidance forces detained mental health patients who smoke into unescorted 'off-grounds' leave without staged assessment, significantly increasing risks of absconding, …
|
1/1 |
| 21 Feb 2019 |
Evie Wright
2019-0063 · Maria Voisin
A long-planned footbridge to eliminate risk at a level crossing has not been built for decades due to stalled plans and unclear …
|
2/2 |
| 8 Feb 2019 |
Jean Cutler
2019-0040 · James Bennett
The nursing home had an inconsistent approach to falls prevention from wheelchairs, an over-reliance on staff intervention, and an inadequate post-incident investigation …
|
1/1 |
| 7 Feb 2019 |
Stephen Kennedy
2019-0039 · Louise Hunt
A patient couldn't access recommended psychological therapy due to internal service barriers and long waiting lists. Additionally, a severe lack of acute …
|
3/3 |
| 31 Jan 2019 |
Andrew Carr
2019-0038 · Louise Hunt
Critical information on a prisoner's drug history was missed by the receiving prison, while drugs could be passed through the plumbing system, …
|
0/3 |
| 25 Jan 2019 |
Stephen Pettitt
2019-0037 · Karen Dilks
There is a lack of appropriate national guidelines for implementing new interventional procedure programs and the necessary associated training, posing a risk …
|
1/2 |
| 28 Jan 2019 |
Simon Barber
2019-0036 · Tanyka Rawden
Inadequate risk assessments by First Class Care and staff's lack of awareness regarding the importance of reporting safety incidents posed a risk …
|
1/1 |
| 29 Jan 2019 |
Sophie Holman
2019-0035 · Shirley Radcliffe
Fragmented asthma care lacked coordinated records, long-term management plans, and guideline adherence, resulting in missed risk factors, excessive medication, and no clear …
|
1/2 |
| 28 Jan 2019 |
Terence Penney
2019-0034 · Paul Smith
A fatal fire resulted from a vapour leak in a relatively new domestic fridge, highlighting a potential widespread safety risk with similar …
|
0/3 |
| 6 Mar 2019 |
Michael Henderson
2019-0037A · Kirsty Gomersal
A road with unusual features, despite appropriate signage, facilitates excessive speeding and has a history of multiple fatal collisions. Traffic calming measures …
|
2/1 |
| 28 Jan 2019 |
Jack Hubbard
2019-0033 · ME Hassell
The nightclub's protocol for calling an ambulance, requiring duty manager approval and a second set of observations, created dangerous delays in emergency …
|
0/1 |
| 28 Jan 2019 |
Conor Crutchley
2019-0032 · Christopher Morris
The Early Intervention Team lacks specialist substance abuse workers for dual-diagnosis patients, and significant waiting times for talking therapies are hindered by …
|
1/1 |
| 24 Jan 2019 |
Olive Johnson
2019-0031 · Paul Cooper
Concerns include the failure to dispatch first responders, frequent exceeding of ambulance response times, and a problematic system that cancels initial waiting …
|
1/1 |
| 14 Feb 2019 |
Matthew Hamilton
2019-0050 · Jeremy Chipperfield
Individuals released from custody are unaware that reduced drug tolerance post-abstinence risks fatal overdose if pre-custody consumption levels are resumed.
|
1/1 |
| 14 Feb 2019 |
Kenneth Whittington
2019-0049 · Veronica Hamilton-Deeley
Hospital failures included missing post-operative catheter instructions, an unchecked epidural disconnection despite patient pain, and a system preventing direct consultant follow-up after …
|
1/1 |
| 13 Feb 2019 |
Matthew Lewis
2019-0048 · Graeme Hughes
Confusing and inconsistent call handler instructions to police officers during a hanging incident created ambiguity between scene preservation and life preservation, risking …
|
2/2 |
| 13 Feb 2019 |
Branko Zdravkovic
2019-0047 · Stephen Nicholls
Detainee healthcare staff were incorrectly advised to use ACDT procedures instead of statutory Rule 35(2) reports, and lacked a formal system to …
|
1/1 |
| 12 Feb 2019 |
Heather Carey
2019-0046 · Andrew Bridgman
Insufficient funding and staffing led to excessively long waiting times for urgent psychotherapy, which was not comparable to physical life-threatening illnesses, causing …
|
2/2 |
| 11 Feb 2019 |
Paul Gillam
2019-0045 · Guy Davies
Concerns relate to the flawed operation of the dual diagnosis policy, inadequate development and implementation of the delivery plan, and a poor …
|
1/3 |