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 |
|---|---|---|
| 3 Oct 2018 |
Charlotte Tripper
2018-0327 · Zafar Siddique
A bus driver practice of avoiding eye contact with other drivers at junctions may increase the risk of collisions.
|
1/1 |
| 10 Oct 2018 |
Robin McEwan
2018-0325 · John Broadbridge
Disconnected communication between private therapy and GPs, lack of guidance on self-help resources, and insufficient involvement of family support for suicidal patients …
|
1/1 |
| 28 Sep 2018 |
Donald Berry
2018-0324 · Alison Mutch
The report outlined the medical cause of death resulting from injuries sustained years earlier, but did not detail specific coroner's concerns for …
|
3/4 |
| 27 Sep 2018 |
Mary Ryder
2018-0323 · Alison Mutch
Post-operative care failed to provide sufficient anticoagulation therapy and clinical review for a patient with decreased mobility, and NICE guidance for D-dimer …
|
1/1 |
| 18 Oct 2018 |
Joseph Grantham
2018-0322 · Alison Mutch
Key concerns include significant delays in discharge paperwork and specialist letters, unclear care responsibility, missing patient notes, inadequate instructions for community monitoring, …
|
0/3 |
| 18 Oct 2018 |
Anne Roberts
2018-0321 · Ravi Sidhu
Inadequate training for bank staff on choking risks, poor dissemination of this information in patient records, and difficulties managing choking risks alongside …
|
0/2 |
| 19 Oct 2018 |
Robert McLoughlin
2018-0320 · Jonathan Leach
The jury identified errors and omissions in the care of an HMP Leeds inmate, which potentially contributed to his death by ligature.
|
0/1 |
| 16 Oct 2018 |
Jordan Sheils
2018-0319 · Martin Fleming
The council is delaying the implementation of anti-climbing mesh and CCTV cameras on a bridge, despite measures to deter tragedies being under …
|
1/1 |
| 23 Oct 2018 |
Nicola Lawrence
2018-0318 · Jonathan Leach
A critical concern was that some prison staff lacked essential cardiopulmonary resuscitation (CPR) training, both initial and refresher, jeopardizing emergency response.
|
1/1 |
| 24 Oct 2018 |
Catherine Gibbon
2018-0317 · ME Hassell
Significant safety failures included inadequate health pledge guidance, untrained staff for medical conditions, insufficient CCTV monitoring with a broken camera, lack of …
|
0/2 |
| 24 Oct 2018 |
Maximilien Kohler
2018-0316 · Fiona Wilcox
Misdiagnosis of ASD was linked to over-reliance on questionnaires and less experienced clinicians, compounded by a lack of services for chronic, complex …
|
2/4 |
| 24 Oct 2018 |
Jennifer Lacey
2018-0315 · Fiona Wilcox
Concerns were raised about dangerous, addictive drugs being freely available online and prescribed by foreign doctors without patient contact or GP record …
|
1/2 |
| 25 Oct 2018 |
Andrea Franzosi
2018-0314 · Katy Skerrett
Inadequate supervision of junior doctors on wards, specifically regarding patient discharges occurring without examination by a senior practitioner.
|
0/1 |
| 23 Oct 2018 |
Allan Shepard
2018-0313 · Angharad Davies
Response times for falls were missed due to inadequate staffing with one-person responder units, and crucial updated patient information was not passed …
|
0/2 |
| 25 Oct 2018 |
David Sargeant
2018-0312 · Guy Davies
The patient could not receive an ADHD diagnosis or treatment due to commissioning gaps, lack of specialist psychiatrists, and impracticalities of out-of-county …
|
1/1 |
| 25 Oct 2018 |
Eileen Cooke
2018-0311 · Kevin McLoughlin
A frail elderly patient was prematurely discharged with unresolved medical issues, inadequate care planning, and without a 'best interests' meeting or family …
|
1/1 |
| 29 Oct 2018 |
Karl Brunner
2018-0310 · Martin Oldham
The incident highlights a risk of future deaths where individuals swallow drugs during police stops, requiring a review of procedures for managing …
|
1/2 |
| 29 Oct 2018 |
Thomas McAuley
2018-0309 · Andrew Harris
Disjointed communication and lack of universal access to medical records (DPMFs) across custody and prison healthcare services mean vulnerable individuals' medical assessments …
|
1/4 |
| 29 Oct 2018 |
Elizabeth Self
2018-0308 · Christopher Dorries
Senior doctors lacked training in making proper X-ray requests. A communication breakdown caused a valid CT request to remain unattended for hours, …
|
1/1 |
| 29 Oct 2018 |
Rosario Cordero-Sanz
2018-0307 · ME Hassell
Special police officers lacked essential equipment and training in mental health and missing person processes. Communication failures and inability to access critical …
|
1/1 |