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 |
|---|---|---|
| 9 Jan 2019 |
Diana Gudgeon
2019-0015 · Hassan Shah
Inadequate 111/EMAS triaging, particularly for sepsis, resulted in delayed response. A shortage of ambulances and a high threshold for escalation in the …
|
2/2 |
| 11 Feb 2019 |
Madeline Staples
2019-0041 · John Gittins
Persistent, unacceptable delays in patient handovers at emergency departments continue to result in long ambulance waits and unavailable resources, despite previous warnings, …
|
0/3 |
| 19 Dec 2018 |
Henry Curtis-Williams
2018-0397 · Sean Cummings
A culture of inadequate contemporaneous note-taking, especially regarding suicidal ideation, and informal, unrecorded staff communication led to critical information being lost. Junior …
|
1/1 |
| 6 Nov 2018 |
Ryan Williams
2018-0341 · Ian Pears
Unsupervised, unmanned stations pose a risk, as vulnerable individuals can remain on premises for extended periods without any oversight or means of …
|
0/1 |
| 6 Nov 2018 |
Gerwyn Thomas
2018-0342 · Jonathan Layton
Insufficient dietetic staff, lack of mandatory training for nutritional assessment tools, and nursing staff's failure to act on doctor referrals to dietetics …
|
1/1 |
| 5 Nov 2018 |
Gareth Jones
2018-0340 · Geraint Williams
The road surface quality was below Highways Agency standards for three years, likely contributing to the death. This location has a history …
|
0/1 |
| 2 Nov 2018 |
Karl Cassimjee
2018-0339 · Timothy Brennand
A Mental Health Act assessment lacked collateral history and clear risk formulation, with no collaborative safety planning or adequate information for the …
|
0/2 |
| 1 Nov 2018 |
Billie Lord
2018-0338 · Thomas Osborne
The mental health inpatient facility uses inappropriate three-bedded dormitories, which contributed to patient stress and requires modernization according to Royal College of …
|
1/1 |
| 1 Nov 2018 |
Colette Dunn
2018-0337 · Thomas Osborne
A full Mental Health Act assessment was omitted before discharge despite police concerns. A lack of clear discharge protocols between agencies and …
|
0/1 |
| 2 Oct 2018 |
Andrew Collins
2018-0336-wp26400 · Andrew Barkley
A severe lack of ambulance resources caused a critical three-hour delay in dispatching a vehicle to a rapidly deteriorating patient, despite urgent …
|
1/1 |
| 4 Mar 2019 |
Meirion James
2019-0460 · Paul Bennett
Concerns exist regarding the content of police training for restraint and Appropriate Adult responsibilities. Criteria for identifying and transporting individuals to a …
|
0/3 |
| 2 Oct 2018 |
Joshua Edwards
2018-0335 · Kevin McLoughlin
Ambulance response was delayed by public event road closures and unclear authority for crews to cross them. Event organizers need to brief …
|
1/1 |
| 27 Sep 2018 |
Sheila Hadfield
2018-0334 · Alison Mutch
A national shortage of suitable care beds for individuals with complex mental health needs resulted in placements in inadequate facilities, with the …
|
1/1 |
| 3 Oct 2018 |
Theresa Button
2018-0333 · Kevin McLoughlin
Inadequate nursing staff levels on a ward for complex patients resulted in poor implementation of treatment plans, insufficient patient support during mealtimes, …
|
1/1 |
| 3 Oct 2018 |
Brian Frost
2018-0332 · 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 …
|
0/3 |
| 1 Oct 2018 |
Michael Hopkins
2018-0331 · Martin Fleming
Hospital discharge practices need review to ensure patients receive adequate information regarding the risk of thromboembolisms following recent surgery after sustaining trauma.
|
1/1 |
| 4 Oct 2018 |
James McLaren
2018-0330 · Andrew Hetherington
Inadequate securing of commercial and communal bins, including unsecured lids and easily opened locks, increases the risk of people sheltering inside and …
|
4/4 |
| 9 Oct 2018 |
Tom Cribley
2018-0329 · Julie Goulding
Repeated systemic failings included poor documentation, delayed escalation of patient deterioration and NMEWS, inadequate clinical handovers, and delayed administration of crucial antibiotics …
|
0/7 |
| 27 Feb 2019 |
Janie McFadyen
2019-0474 · Nigel Meadows
No specific concerns were detailed in the provided text.
|
2/1 |
| 26 Feb 2019 |
Keith Heatley
2019-0478 · Ian Boyes
There was a lack of documented multidisciplinary decision-making and policy guidance regarding leave for informal patients, coupled with inconsistent recording of MDT …
|
1/1 |