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 193 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
22 Jan 2019	Ann Swoffer 2019-0026 · Louise Hunt Hospital practices diverged from national guidelines, junior staff failed to escalate issues during weekends due to senior staff absence, and a lack …	West Midlands Birmingham and Solihull	University Hospitals Birmingham NHS Trust	1/1
17 Jan 2019	Mylon Sheppard 2019-0025 · Sean McGovern Failures included ineffective oversight of duty worker decisions, poor waiting list management, unclear processes for patient non-attendance, and inadequate family involvement in …	West Midlands Warwickshire	Coventry & Warwickshire Partnership Trust Coventry NHS Trust	0/2
21 Jan 2019	Neil Black 2019-0024 · Louise Hunt Inadequate coordination and unclear responsibilities between prison nursing teams, compounded by a lack of protocols for examining critical injection and DVT sites.	West Midlands Birmingham and Solihull	Birmingham Community Healthcare NHS Trust	1/1
17 Jan 2019	Mark Harris 2019-0023 · Jacqueline Devonish Police received incorrect name spelling and unclear instructions for a welfare check, indicating critical communication failures and a lack of agreed protocols …	East of England Suffolk	Emergency Operation Centre Norwich Melbourne Ambulance Station	0/2
23 Jan 2019	Gail Bailey 2019-0027 · Paul Smith A critical communication breakdown occurred between paramedics pre-alerting the hospital and the hospital's readiness for a critically ill patient, raising significant concerns …	East Midlands Lincolnshire	United Lincolnshire Hospitals NHS Trust	0/1
15 Jan 2019	Marie Millward-Winter 2019-0020 · Rachel Galloway Administration of anticoagulation medication after a head injury, advised by ambulance technicians, likely worsened an internal bleed and contributed to death.	North West Manchester (City)	Each Step Nursing Home NORTH WEST AMBULANCE SERVICE	1/2
15 Jan 2019	John Preece 2019-0019 · Roger Barkley Significant failures in falls management, head injury recognition, and neuro observation training among staff, compounded by a lack of appropriate monitoring and …	Wales South Wales Central	Cardiff and Vale University Health … Nursing & Midwifery Council	2/2
19 Dec 2018	Kirsty Walker 2018-0396 · Anna Crawford Prolonged delays (months) in transferring prisoners requiring secure hospital care under the Mental Health Act, far exceeding recommended timeframes, are caused by …	South East Surrey	Department of Health and Social … NHS England	2/2
18 Dec 2018	Ruth Edwards 2018-0395 · Rachel Knight Patient discharge after an overdose failed to include psychiatric liaison assessment, passing critical responsibility to the family. Inadequate history-taking led to underestimated …	Wales SouthWales Central	Cardiff and Vale University Health … West Quay Surgery	2/2
18 Dec 2018	Susan Longden 2018-0394 · Peter Harrowing The NHS Pathways algorithm fails to prompt questions about recent surgery for severe abdominal pain, and NHS 111 advisors don't adequately prioritise …	South West Avon	NHS England	1/1
19 Dec 2018	Michal Netyks 2018-0393 · Andre Rebello Prison Custody Officers lack training for delivering deportation papers, and foreign national prisoners have unequal access to legal advice. Mezzanine safety at …	North West Liverpool & Wirral	Home Office MoJ	1/2
18 Dec 2018	Natalie Hunter 2018-0392 · Caroline Sumeray The Isle of Wight NHS Trust frequently fails to provide timely discharge summaries to GPs, hindering continuous patient care, especially for mental …	South East Isle of Wight	St Mary’s Hospital NHS Trust	0/1
18 Dec 2018	Jacqueline Valvona 2018-0391 · Caroline Sumeray A lack of safe pedestrian crossing on a busy road near a popular pub, especially for elderly residents with mobility issues, may …	South East Isle of Wight	Island Roads Isle of Wight Council	2/2
12 Dec 2018	Edward Farmer 2018-0390 · Karen Dilks A national campaign is needed to highlight the inherent risks of rapid alcohol consumption and initiation events, focusing on identifying at-risk individuals …	North East Newcastle upon Tyne	Department for Education	6/1
18 Dec 2018	John Duckenfield 2018-0389 · David Urpeth Care home staff dishonesty regarding patient observations and GP calls, coupled with inaccurate records, indicated serious failures. Management surprisingly deemed the care …	Yorkshire and the Humber South Yorkshire (West)	Brancaster Care	1/1
18 Dec 2018	John Delahaye 2018-0388 · Emma Brown National risk assessment templates are unclear on medication, and unreliable electronic records impede identifying past medical conditions. Healthcare staff are also inconsistently …	West Midlands Birmingham and Solihull	Birmingham and Solihull Mental Health … Birmingham Community NHS Trust G4S MoJ	1/5
14 Dec 2018	Barnaby Aylward 2018-0387 · John Broadbridge Agencies did not collectively address the risks to a social housing tenant with serious mental illness, including heavy smoking and accumulating clutter. …	Yorkshire and the Humber West Yorkshire (West)	SW Yorks NHS Trust Together Housing West Yorkshire Fire and Rescue …	1/3
12 Dec 2018	Benjamin Williamson 2018-0384 · Andrew Cox The CMHT repeatedly discharged a patient with co-occurring mental health and alcohol issues, while Addaction failed to communicate with his GP or …	South West Cornwall and Isles of Scilly	Addaction Kernow Clinical Commissioning Group	2/2
10 Dec 2018	Christopher McGuffie 2018-0386 · Jeremy Chipperfield Railway stations lack immediate and effective alert systems for detecting and reporting persons on the line.	North East County Durham and Darlington	Northern Rail Limited	1/1
12 Dec 2018	Neil Swaisland 2018-0385 · Thomas Osborne The withdrawal of funding for MIND's counselling services by the Council and CCG risks future deaths from self-harm and suicide among vulnerable …	South East Milton Keynes	Milton Keynes Clinical Commissioning Group Milton Keynes Council	2/2