Pamela Sunter
AI-generated concerns summaryThe coroner noted that old two-week wait forms remaining on the system could cause confusion and suggested prioritising their removal when new forms are introduced.
Addressed to: Cancer Alliance
Source · Prevention of Future Deaths
Prevention of Future Deaths Reports
Browse 6,471 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
Mohammed Ahmed
AI-generated concerns summaryThe coroner noted expert evidence suggesting a combination of Olanzapine and Spice could cause adverse allergic reactions, and raised concerns about whether this potential interaction is sufficiently known to clinicians nationally.
Addressed to: Department of Health and Social Care; NHS England
Graham Tailby
AI-generated concerns summaryThe coroner noted the absence of an intraosseous drill on crash trolleys, identifying it as a potential intervention that could prevent future deaths during emergency responses.
Addressed to: Pennine Acute Hospitals NHS Trust
Marjorie Gartside
AI-generated concerns summaryThe coroner noted inaccurate patient mobility information provided by the hospital, potentially leading to unsuitable equipment. Concerns were also raised about the robustness of discharge processes, including a lack of handover and missing prescribed medication.
Addressed to: Pennine Acute Hospital NHS Trust
Ellie Long
AI-generated concerns summaryThe coroner identified inadequate electronic record-keeping practices, including handwritten notes not integrated into official records. Concerns also related to inconsistent communication and information sharing with external agencies like the GP and school.
Addressed to: Norfolk & Suffolk NHS Trust
Mark Parry
AI-generated concerns summaryThe coroner noted an absence of published guidelines from the Health and Safety Executive for mechanics and their employers on safe practices for working with air suspensions on Heavy Goods Vehicles.
Addressed to: Health and Safety Executive
Katharine Dowling
AI-generated concerns summaryThe coroner noted a lack of clear national guidance, consistent support, and appropriate environments for patients with Autism Spectrum Disorder and co-existing mental health diagnoses. There were also concerns regarding the inconsistent implementation and monitoring of ASD training for staff across the UK.
Addressed to: NHS England
Tamsin Grundy
AI-generated concerns summaryThe coroner noted Miss Grundy's distress from seeing over 25 members of the Crisis Resolution Home Treatment Team, requiring her to repeatedly explain her difficulties. There was no definitive, timed action or named person responsible for addressing this issue, despite it being raised.
Addressed to: Norfolk & Suffolk NHS Trust
David Mobsby
AI-generated concerns summaryBrighton and Hove City Council's health and safety advice to Blatchington Mill School omitted work at height, leading to inadequate training and risk assessments for an employee using ladders. The employee worked unsupervised, emergency response was delayed, and managing staff lacked appropriate training.
Addressed to: Blatchington Mill School; Brighton and Hove City Council; Department of Education
Nora Bruton
AI-generated concerns summaryThe coroner raised concerns about the inadequate dissemination of revised clinical risk assessment training for harmful substance abuse and the lack of a robust review of crisis call communication protocols. There was also a prolonged, uncompleted review of the Home Treatment Team model.
Addressed to: Birmingham & Solihull Mental Heath NHS Trust
Christopher Gibbs
AI-generated concerns summaryConcerns were raised about the lack of dedicated cycle lanes on the A338 dual carriageway and the absence of warning signs to alert drivers to the potential presence of cyclists.
Addressed to: Bournemouth Borough Council; Dorset County Council
Steven Key
AI-generated concerns summaryThe coroner highlighted inadequate low wooden fencing along the railway line, which allowed easy access to the track where trains travel at high speeds, risking future deaths.
Addressed to: Network Rail
Brian Havard
AI-generated concerns summaryThe coroner identified that doctors lacked awareness and access to electronic ambulance records, leading to missed patient information. Concerns were also raised about a senior consultant's insufficient professional curiosity and the absence of clear systems for senior review of junior doctor cases.
Addressed to: Norfolk and Norwich University Hospital
Justin Brown
AI-generated concerns summaryThe coroner noted concerns regarding the hospital's discharge process for addiction patients, specifically the lack of an agreed protocol and insufficient collaboration with commissioned drug services to monitor referrals and patient outcomes.
Addressed to: Suffolk County Council
Christopher Bevan
AI-generated concerns summaryThe coroner notes concerns regarding the use of ladders in work, specifically their potential use on slippery surfaces, without being footed or securely fastened at the top, which could present a risk to life.
Addressed to: Holloway Assistant Coroner for Blackpool & Fylde; Iam Tim
Wayne Rodgers
AI-generated concerns summaryThe coroner noted limited ambulance availability on the Isle of Wight, particularly during large events like Cowes Week, and suggested organisers consider employing private medical services on-site. The report also highlights a need to review the Crisis Management Plan, mandatory safety equipment, and criteria for abandoning racing.
Addressed to: Cowes Week Limited; Emergency Preparedness, Resilience and Response; Resilience and Response, Isle of Wight NHS Trust; Jubilee Stores; Licensing & Business Support, Regulatory Services
Colin Bailey
AI-generated concerns summaryThe coroner noted that national NICE guidelines on CT scans after a head injury in patients on anti-coagulants differentiate by medication type. Clinicians indicated a scan should be undertaken regardless, raising concern for updated national guidance.
Addressed to: N.I.C.E
Ann Corfield
AI-generated concerns summaryThe coroner identified gaps in medication information transfer between trusts and poorly completed fluid balance charts. Concerns were also raised about delays in prescribing and administering prophylactic anticoagulation, and the mental health unit's inability to administer intravenous fluids.
Addressed to: Greater Manchester Mental Health NHS Trust; Pennine Acute Hospitals NHS Trust
Bram Radcliffe
AI-generated concerns summaryThe coroner identified that there is no British Standard for the fixing of stone fireplace surrounds, only for their manufacture, and that their installation is not considered 'building work' under current building regulations. This indicates a gap in regulatory oversight for fireplace surround installations.
Addressed to: Ministry of Housing, Communities and Local Government; Stone Federation of GB
Matthew Bilby
AI-generated concerns summaryThe coroner noted the A16/B1166 junction is an "accident blackspot" and poses an ongoing risk to road users. Concerns were raised that the junction should be reconfigured as a roundabout or have traffic calming measures implemented.
Addressed to: Department for Transport; Lincolnshire County Council