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 |
|---|---|---|
| 5 Dec 2018 |
Sylvia Mitchell
2018-0383 · Zafar Siddique
Inadequate communication between the Trust and GP regarding the urgent removal of a pessary, and insufficient follow-up for pessary use, led to …
|
3/2 |
| 19 Oct 2018 |
Trystan Bryant
2018-0382 · Ian Arrow
Stationary ambulance doors that cannot be locked pose a risk to police containment of individuals detained under the Mental Health Act, potentially …
|
1/2 |
| 11 Dec 2018 |
John Mayhew
2018-0381 · Crispin Oliver
Clarification, redrafting, and improved guidance are needed for the PSI64/2011 section on first case reviews of ACCT assessments to ensure consistent and …
|
0/3 |
| 11 Dec 2018 |
Rowan Lloyd
2018-0380 · Brendan Allen
A busy road junction, frequently used by school children, lacks safe pedestrian crossings, cycle lanes, or barriers, leading to obscured views and …
|
1/1 |
| 6 Dec 2018 |
John Kirby
2018-0379 · Veronica Hamilton-Deeley
Evidence from the inquest revealed matters of concern and a risk of future deaths, necessitating action.
|
1/2 |
| 6 Dec 2018 |
Veronica Gregory
2018-0377 · Nigel Meadows
Care plans were inadequate, lacked specific risk issues, and were not appropriately reviewed or reassessed, either after incidents or as routine practice.
|
1/1 |
| 6 Dec 2018 |
Simon Healey
2018-0378 · Heidi Connor
NEWS policies at private hospitals should be reviewed, particularly regarding escalation of care for critically unwell patients, considering their limited critical care …
|
1/2 |
| 28 Nov 2018 |
Ronald Houchin
2018-0376 · Tanyka Rawden
Falls risk assessments were not consistently followed, resulting in inadequate assistance and supervision for mobilising, and multiple preventable falls for the patient.
|
0/1 |
| 30 Nov 2018 |
Thomas Nicol
2018-0375 · Geoffrey Sullivan
Significant delays in transferring prisoners experiencing acute mental health crises to appropriate secure hospitals potentially endanger lives.
|
2/3 |
| 30 Nov 2018 |
Bradley Brown
2018-0374 · Lisa Hashmi
Late prisoner transfers, particularly on weekends, are unsafe due to unavailable mental health assessments and limited access to healthcare records, heightening risk …
|
1/2 |
| 29 Nov 2018 |
Luke Saxton
2018-0373 · Robert Turnbull
The absence of street lighting in a dark area with bus stops near a popular venue creates a significant road safety risk …
|
1/1 |
| 27 Aug 2018 |
Peter Gledhill
2018-0371 · Martin Fleming
The safety of a pathway running along a steep river embankment requires urgent review, specifically considering the appropriateness of installing fencing to …
|
1/1 |
| 21 Nov 2018 |
Ursula Keogh
2018-0370 · Martin Fleming
Inconsistent and contradictory advice from GPs and schools regarding CAMHS referrals, exacerbated by a school lacking the necessary Psychology Team, highlighted poor …
|
2/3 |
| 1 Aug 2018 |
Jerome Jones
2018-0369 · Joanne Lees
Insufficient specific checks and a lack of policy for prisoners with multiple NPS use, combined with poor communication of medical risks and …
|
2/3 |
| 20 Nov 2018 |
Suleyman Yalcin
2018-0368 · Andrew Walker
Insufficient refresher training in emergency response driving, police under-resourcing, and inadequate terminology for communicating urgency posed risks during critical incidents.
|
2/1 |
| 22 Nov 2018 |
Matthew Craven
2018-0365 · Alison Mutch
A patient died from pregabalin toxicity after consuming excess prescribed medication post-discharge, raising concerns about managing medication risks for individuals with a …
|
1/1 |
| 22 Nov 2018 |
Savannah-Rose Owen
2018-0367 · Alison Mutch
Multi-purpose nursing pillows lack specific safety regulations and have inconsistent, often misleading, warning labels that are easily lost, promoting unsafe sleep practices …
|
2/2 |
| 8 May 2019 |
Bernard O’Flynn
2019-0488 · Christopher Williams
Concerns remain that policies for medical emergencies in state custody, outside of Code Red/Blue scenarios, lack input from an emergency medicine expert, …
|
0/1 |
| 8 May 2019 |
Edward Hearn
2019-0479 · Andrew Harris
A system failure led to a critical high globulin blood test result in A&E not being followed up, delaying diagnosis. Additionally, prescribing …
|
3/6 |
| 22 Nov 2018 |
Karen Moran
2018-0336 · Alison Mutch
The deceased had a long-term addiction to prescribed medication, but repeat prescriptions continued without a referral to address the addiction, giving her …
|
1/1 |