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 192 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
12 Feb 2019	Anthony Watson 2019-0044 · James Bennett A critically ill mental health patient could not access immediate inpatient treatment due to a severe lack of local beds and distant, …	West Midlands Birmingham and Solihull	Birmingham and Solihull Clinical Commissioning … NHS England	2/2
11 Feb 2019	Calary Davis 2019-0043 · David Regan Maternity services suffered from an incomplete action plan, institutional stress from a merger, a culture of not performing essential procedures at night, …	Wales South Wales Central	Cwm taf University Health Board	1/1
11 Feb 2019	Robert Hughes 2019-0042 · Katy Skerrett The 'triangle of care' approach, which facilitates family involvement with patient permission in mental health care, is not consistently applied, potentially limiting …	South West Gloucestershire	2gether NHS Trust	1/1
4 Jan 2019	Nicky Reilly 2019-0014 · Joanne Kearsley The provided text is incomplete and does not detail specific concerns regarding future deaths, primarily describing the deceased's history and transfer.	North West Manchester (North)	Greater Manchester Mental Health & … HM Prisons and Probation Service	2/2
10 Jan 2019	Christopher Seal 2019-0013 · Maria Voisin Multiple failures in information sharing, record keeping (RIO system), and lack of "no response" or "welfare check" policies in primary care, exacerbated …	South West Avon	Avon and Wilshire Mental Health …	1/1
11 Jan 2019	Ricardo Holgate 2019-0012 · Louise Hunt Inadequate management of illicit substance misuse in prison requires further steps, including implementing CCTV on all wings and airport-style scanners at entry …	West Midlands Birmingham and Solihull	G4S HM Prisons and Probation Service MOJ	1/3
10 Jan 2019	Natasha Chin 2019-0011 · Caroline Topping Significant failures in prison medication management, including lack of information sharing with officers, unclear protocols, absent audits for critical processes, inadequate response …	South East Surrey	Chief Inspector of Prisons Care Quality Commission MOJ Police and Prisons Ombudsman	1/4
10 Jan 2019	Richard Lockley 2019-0010 · Andrew Haigh Poor inter-hospital communication during patient transfers and difficulties securing specialist gastroenterology beds risk patient safety and timely care.	West Midlands Staffordshire (South)	University of North Midlands Hospital …	1/1
10 Jan 2019	Michael Flynn 2019-0008 · Alison Mutch The report identifies a lack of EWS monitoring in the post-operative recovery area, failure to adhere to Trust policy regarding monitoring and …	North West Manchester (South)	Tameside General Hospital	1/1
10 Jan 2019	Malcolm Shaw 2019-0007 · Christopher Morris A fundamentally flawed patient safety investigation into a fall highlighted inadequate investigation training and a lack of guidance for frontline staff on …	North West Manchester (South)	Stockport NHS Trust	1/1
9 Jan 2019	Marian Hoskins 2019-0005 · Alison Hewitt An unclear system for obtaining full and informed consent, particularly lacking sufficient outpatient discussion prior to admission, led to insufficient patient information …	London City of London	Barts Health NHS Trust	1/1
2 Jan 2019	Alexandre Parr 2019-0001 · David Ridley The provided text is incomplete and does not detail any specific concerns regarding future deaths.	South West Wiltshire and Swindon	Civil Aviation Authority	1/1
16 Jan 2019	George Thompson 2019-0022 · Christopher Morris Insufficient doctor staffing meant no home visits could be undertaken even if clinically indicated, due to one doctor covering all duties and …	North West Manchester (South)	Highlands and Trafalgar Square Surgery	1/1
11 Jan 2019	Amanda Briley 2019-0021 · Lydia Brown Lack of commissioned services for autism management and local inpatient provision forces out-of-area mental health placements, hindering family contact and local support.	East Midlands Leicester City and Leicestershire South	East Leicestershire and Rutland Clinical …	2/1
11 Jan 2019	Ruth Gregory 2019-0017 · Alison Mutch Regular unsupervised communal areas in the care home led to resident injuries from falls, highlighting inadequate risk management and supervision arrangements.	North West Manchester (South)	Reinbek Care Home	1/1
11 Jan 2019	Elizabeth Curtis 2019-0018 · Maria Voisin Concerns arose that patient mobility, a key indicator of declining health, was not systematically assessed alongside other wellness scores in hospital care.	South West Avon	NHS Improvements	1/1
11 Jan 2019	Jacqueline Elliott 2019-0016 · Alison Mutch Inadequate medication review processes, poor documentation, high-volume painkiller prescribing despite overdose history, and lack of continuity of care led to reliance on …	North West Manchester (South)	Delamere Medical Practice	1/1
18 Jan 2019	Norman Pirie 2019-0030 · Edwin Buckett A surgical cuff device was used outside manufacturer guidelines in a non-emergency procedure, increasing the risk of device failure and the need …	London London Inner (North)	Royal London Hospital	1/1
23 Jan 2019	Tyrone Givans 2019-0028 · ME Hassell Widespread Spice use, an unfit-for-purpose IT system causing incomplete medical records, and a lack of awareness and support for a deaf prisoner …	London London Inner (North)	Care UK HMP Pentonville National Offender Management Service	2/3
25 Jan 2019	Gareth Bickerstaff 2019-0029 · Lisa Hashmi Dangerous discrepancies exist between national and local ambulance guidance on the 15-minute timeframe for resuscitation, creating ambiguity and potential misinterpretation regarding when …	North West Manchester (North)	Joint Royal Colleges Ambulance Liaison …	0/1