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 Nov 2018 |
Roy Burgess
2018-0364 · Sarah Slater
The hospital's Early Warning System was not adhered to, leading to missed senior medical reviews. Inadequate and non-chronological record-keeping by clinicians resulted …
|
0/2 |
| 21 Nov 2018 |
Ben Walmsley
2018-0363 · Joanne Kearsley
The school's IT system lacked a mechanism to alert staff when students attempted to access blocked self-harm content, relying solely on teacher …
|
0/1 |
| 3 Oct 2018 |
Canon Frost
2018-0362 · Nigel Parsley
Unsafe living conditions, specifically loose flooring, were unaddressed in a frail, elderly priest's accommodation, as diocesan welfare visits failed to conduct health …
|
1/3 |
| 13 Nov 2018 |
Matthew Arkle
2018-0361 · Nigel Parsley
Failures in mental health patient risk assessment, undocumented family concerns about unescorted leave, and significant delays in raising the alarm due to …
|
1/1 |
| 19 Nov 2018 |
Beryl Walsh
2018-0359 · J Robinson
There were multiple missed opportunities to identify the deceased as a high falls risk, escalate care to the falls team, or implement …
|
1/1 |
| 16 Nov 2018 |
Emmett Gillah
2018-0357 · Darren Stewart
Discharge letters lacked detail for GPs, KMPT failed to maintain post-discharge contact as per policy, and communication with patient families regarding discharge …
|
0/1 |
| 28 Aug 2018 |
Peter Lett
2018-0356 · Stuart Fisher
There is a significant lack of HSE guidance for historic and heritage equipment, much of which is unguarded and dangerous, creating a …
|
1/1 |
| 20 Nov 2018 |
Austin Thomas
2018-0360 · Joanne Lees
Drivers of heavy machinery could be distracted by high-volume music, lacking a specific policy. The drug policy was inadequate, with no random …
|
0/1 |
| 16 Nov 2018 |
Sheila Graham
2018-0355 · Margaret Jones
Prolonged social isolation for a patient with C. difficile negatively impacted her well-being, compounded by inadequate nutritional information recording and assessment.
|
0/1 |
| 16 Nov 2018 |
Dawn Gill
2018-0354 · ME Hassell
The hospital lacked a nursing care plan addressing the patient's likely continued drug use while admitted, and the drug chart went missing. …
|
1/1 |
| 12 May 2018 |
Charles Grainger
2018-0353 · Rachel Syed
Systemic barriers prevented social workers from sharing crucial falls history with multi-agencies, and investigations failed to adequately review past falls risk assessments, …
|
0/3 |
| 15 Nov 2018 |
Kendall Chadwick
2018-0352 · Andrew Haigh
The coroner recommends a review of a bend on the road close to Leese Hill, to see if additional safety steps would …
|
1/1 |
| 26 Oct 2018 |
Timothy Mason
2018-0351 · Roger Hatch
Failures in the Emergency Department led to incorrect diagnosis and treatment of sepsis, and the discharge of an unwell patient. Concerns include …
|
1/2 |
| 15 Apr 2019 |
Thomas Collings
2019-0260-wp26715 · Derek Winter
Further learning and explicit timescales are needed for implementing and refreshing training on the crucial maintenance of lead attachments for medical monitors.
|
2/2 |
| 13 Nov 2018 |
Thomas Jackson
2018-0352-wp26415 · Andrew Haigh
Poor record-keeping, inadequate preparation and attendance at multidisciplinary meetings, and staff unfamiliarity with Clozapine's significance hindered patient care. Inaccuracies in serious incident …
|
1/2 |
| 4 Nov 2018 |
Patricia Chambers
2018-0350 · Richard Furniss
Concerns were identified regarding practices at West London Mental Health Trust, indicating a risk of future deaths if appropriate action is not …
|
0/2 |
| 19 Oct 2018 |
John Lee
2018-0349 · Ian Wade QC
A clerical error severely delayed an urgent vascular appointment, changing an elective procedure to an emergency and contributing to the patient's death, …
|
0/1 |
| 9 Nov 2018 |
John Graham
2019-0348-wp26412 · Catherine McKenna
Lack of routine installation of carbon monoxide detectors in residential accommodation rented by Rochdale Borough Housing Limited creates a risk of future …
|
1/1 |
| 12 Nov 2018 |
Joseph Page
2018-0347 · Graeme Hughes
Hospital policies for storing patients' own medication were breached, allowing a patient unsupervised access to prescription drugs which led to an overdose.
|
0/1 |
| 5 Nov 2018 |
Daniel Stokes
2018-0346 · Neil Cameron
Prison healthcare staff possessed diazepam but were not trained or authorised to administer it, potentially hindering response to drug abuse incidents.
|
0/1 |