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 198 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
31 Oct 2018	Dorothy Strickley 2018-0305 · Lydia Brown Critical discharge instructions for anti-embolism stockings were not communicated, leading to the patient's unawareness of their necessity. This highlighted a failure in …	East Midlands Leicester City and Leicestershire South	University of Leicester Hospitals NHS …	1/1
23 Oct 2018	Kalma Ram-Henman 2018-0306 · Veronica Hamilton-Deeley Multiple clinical failings included an incomplete fluid chart, unadministered essential medications and fluids despite orders, missed ECG abnormalities, and neglected opportunities to …	South East Brighton and Hove	Brighton & Sussex University Hospitals …	1/1
13 Feb 2019	Sophie Bennett 2019-0476 · John Taylor The care home suffered from inadequate governance, untrained and insufficient staff, poor record-keeping, and ill-conceived changes that negatively impacted residents. Board oversight …	London London (West)	RCI RPFI	0/2
6 Feb 2019	Ruth Whitmore 2019-0473 · Jacqueline Lake Issues included unclear responsibility and lack of awareness for nurses in charge, coupled with an inadequate initial investigation into an incident, which …	East of England Norfolk	Queen Elizabeth Hospital	0/1
5 Feb 2019	Gwyneth Edwards 2019-0472 · Ian Pears Inadequate weekend transfer protocols, staff failing to action NEWS scores, and a flawed Mobile Medic system marking incomplete requests as done, coupled …	East of England Bedfordshire & Luton	Bedford Hospital	0/1
1 Feb 2019	Mary Johnson 2019-0495-wp26975 · Hugh Bricknell Poor communication between staff regarding pre-operative patient feeding and medication adherence, combined with porter availability dictating theatre operations, raised significant safety concerns.	West Midlands Herefordshire	Wye Valley NHS Trust	1/1
31 Jan 2019	Garry Clarkson 2019-0459 · Paul Marks Westfield Lane is a dangerous accident blackspot with a history of multiple fatalities and accidents, highlighting an urgent need for highway safety …	Yorkshire and the Humber East Riding and Kingston-upon-Hull	ERYC Highways Department	1/2
28 Jan 2019	Dennis Warner 2019-0470 · Sean Cummings An elderly patient with advanced dementia received incomprehensible discharge information and inadequate follow-up due to ED overcrowding, suboptimal imaging, delayed senior review, …	London London (West)	Care Quality Commission Royal United Hospital	0/2
25 Jan 2019	Anne-Marie Nield 2019-0477 · Lisa Hashmi Police officers widely misunderstood Domestic Abuse policy, failed to use system markers or recognize non-fatal strangulation as a risk factor, conducted inadequate …	North West Manchester (North)	Manchester Police	1/1
24 Jan 2019	Arun Viswambaran 2019-0487 · Sarah Bourke Excessive waiting times of up to 18 weeks for IAPT therapy and difficulties in contacting the team risked mental health deterioration and …	London London Inner (North)	North East London NHS Trust	0/1
14 Aug 2018	Enric Elliott 2018-0300 · Fiona Wilcox Vulnerable young mothers who book late for maternity care are often excluded from the Family Nurse Partnership due to rigid gestation limits, …	London London Inner (West)	Whittington Health NHS Trust	1/1
13 Aug 2018	Flora Baber 2018-0229 · ME Hassell The patient did not always receive appropriately pureed food or assistance to eat, and there was a delay in referring her to …	London London Inner (North)	Adelaide Medical Centre Compton Lodge Care Home Royal Free Hospital NHS Trust	3/3
27 Sep 2018	Julia MacPherson 2018-0298 · Sonia Hayes Failure to review a patient despite severe side effects and family concerns, inadequate mental capacity assessments, poor record-keeping for off-label medication consent, …	London London (South)	Care Quality Commission Department for Health Oxleas NHS Trust	2/3
26 Sep 2018	Bridget Marie Connell-Graham 2018-0297 · Alison Mutch The lack of a clear national definition for 'cervical trauma' leads to inconsistent approaches in investigating prior history and planning clinical treatment …	North West Manchester (South)	Department for Health	1/1
3 Sep 2018	Andrew Dickson 2018-0296 · Chris Morris Critical information about suicidal ideation from telephone triage is not reliably transferred to the doctor's screen for face-to-face appointments, creating significant safety …	North West Manchester (South)	Edgeley Medical Centre Stockport Medical Group	1/2
4 Sep 2018	Colin Griffiths 2018-0295 · ME Hassell Medical history recording relies solely on verbal communication, leading to inaccuracies, and there is no audit system to verify the accuracy of …	London London Inner (North)	Masta Limited	2/1
3 Sep 2018	Doris Douthwaite 2018-0294 · Chris Morris Vulnerable residents with dementia were left unsupervised due to unclear policies, an ambiguous falls risk assessment tool, and a lack of investigation …	North West Manchester (South)	HC-One	0/1
28 Jun 2018	Stephen Whitehead 2018-0293 · Lisa Hashmi The absence of a national registry for biliary stents creates a risk of "forgotten stents," while national guidelines lack a clear definition …	North West Manchester (North)	British Society of Gastroenterology Department of Health and Social …	2/2
10 Sep 2018	Gladys Williams 2018-0292 · John Gittins Ongoing, multifactorial problems with ambulance delays, emergency department overcrowding, and patient flow continue to risk lives, despite previous warnings and reported mitigation …	Wales North Wales (East and Central)	Betsi Cadwaladr University Health Board Welsh Ambulance Services	0/2
10 Sep 2018	Darren Urquhart 2018-0291 · Geoffrey Sullivan Inadequate railway anti-trespass measures, including poor trespass mat placement, missing platform gates, and insufficient fencing, create a risk of future deaths from …	East of England Hertfordshire	Network Rail	0/1