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.

Response tracker Organisations Advanced search

Keyword

Browse by year

Browse by region

Sort

Reports

6,386 reports · Page 199 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
10 Sep 2018	Elijah Shotade 2018-0290 · Dewi Pritchard-Jones Dangerous road layout design and misleading sat nav directions encourage westbound motorists to remain or enter the eastbound lane after overtaking, significantly …	Wales North West Wales	North & Mid Wales Trunk …	1/1
11 Sep 2018	Kevin Sherwood 2018-0289 · Geoffrey Sullivan Insufficient railway boundary fencing, consisting only of post and wire, in an area frequented by walkers, creates a risk of trespass onto …	East of England Hertfordshire	Network Rail	1/1
10 Sep 2018	Alba Pemberton 2018-0288 · Andrew Walker Protocols for meconium classification and equipment use are inadequate, and there's insufficient obstetric review and multidisciplinary collaboration in birthing centres and low-risk …	London London (North)	Department of Health and Social …	1/1
7 Sep 2018	Scott Carton 2018-0287 · Kevin McLoughin Inadequate psychological support for prisoners with mental health and drug issues upon release, including unsuitable hostel placements without specialist input, compromises rehabilitation …	Yorkshire and the Humber West Yorkshire (East)	MoJ National Probation Service	0/2
12 Sep 2018	Abigail Hall 2018-0286 · David Urpeath The continued absence of a defibrillator and first aid trained staff at the premises creates a critical risk for emergency medical response …	Yorkshire and the Humber South Yorkshire (West)	Derwent Students	1/1
13 Sep 2018	Laila Habibi and Daniel Ghafuri 2018-0285 · Sean McGovern A dangerous diversion road with a history of fatalities lacked crucial 'single carriageway' warning signs, and sat navs directed drivers into the …	West Midlands Warwickshire	Warwickshire County Council	0/1
14 Sep 2018	Paul Ryley 2018-0284 · Emma Brown Unclear Toxbase guidelines for paracetamol overdose re-presentations lead clinicians to misunderstand their applicability, risking patients not receiving crucial treatment for liver toxicity.	West Midlands Birmingham and Solihull	Toxbase	1/1
14 Sep 2018	Daniel Collins 2018-0283 · James Bennett A mental health service transferred a recently suicidal patient's care, requiring the patient to initiate contact with the new service, without proper …	West Midlands Birmingham and Solihull	Birmingham and Solihull Clinical Commissioning … Birmingham Women’s and Children’s NHS …	0/2
14 Sep 2018	Terence Bennett 2018-0282 · Nicholas Rheinberg The jury found that failures in mental healthcare contributed to the death, including inadequate care plans, insufficient staff knowledge of medical records, …	South West Wiltshire and Swindon	Avon and Wiltshire Mental Health … Care Quality Commission NHS England NHS England	1/4
13 Aug 2018	Nana Boateng 2018-0281 · David Ridley Significantly worn road markings and non-functional cat's eyes on a sharp bend create a hazard, potentially causing drivers to lose positional awareness …	South West Wiltshire and Swindon	Wiltshire Council	1/1
31 Dec 2018	Janice Davies 2018-0409 · Graeme Hughes Missing documented observations and pain scores before discharge, alongside absent formal guidance for prescribing oramorph to discharging patients, led to inconsistent and …	Wales South Wales Central	Cwm Taf Morgannwg University Health …	1/1
28 Dec 2018	David Stacey Dianne Hocking A statutory requirement to provide beds for mentally disordered patients in special urgency cases is being ignored, leading to a lack of …	East Midlands Leicester City and Leicestershire South	East Leicestershire Clinical Commissioning Group Heart of England NHS Foundation … Minister for Health	1/3
28 Dec 2018	Gregory Rewkowski 2018-0411 · Joanne Kearsley The coroner notes practical difficulties for nurses raising welfare concerns on an acute ward, unclear reasons for the clinical lead's inaction, failure …	North West Manchester (North)	Greater Manchester Police North West Ambulance Service NHS … Pennine Care NHS Trust	3/3
28 Dec 2018	Joan Wright 2018-0408 · Alison Mutch Issues included inconsistent opioid handling, unaddressed statutory oversight for drug responsibilities, police failure to recognise safeguarding risks in medication errors, and a …	North West Manchester (South)	Department of Health and Social …	1/1
27 Dec 2018	Kenneth Bardsley 2018-0407 · Alison Mutch The coroner raises concerns regarding the lack of minimum qualification standards for lift engineers, the absence of an escalation process for regulatory …	North West Manchester (South)	Care Quality Commission Department for Work and Pensions Health and Safety Executive Lancs & Cumbria Lifts UK …	0/5
24 Dec 2018	Joyce Long 2018-0406 · Crispin Butler The provided text is incomplete and does not detail any specific concerns regarding future deaths related to patient deterioration.	South East Buckinghamshire	Buckinghamshire Healthcare NHS Trust South Central Ambulance Service	0/2
21 Dec 2018	Richard Whale 2018-0404 · Alison Mutch Impeded exit routes and obstructed handrails due to steward placement, coupled with non-compliance with steward codes and lack of audits, compromised public …	North West Manchester (South)	Department for Digital, Culture Media … Manchester United Football Club Trafford Borough Council	3/3
21 Dec 2018	Dorina Zangari 2018-0403 · Shirley Radcliffe Undermined fire safety measures, absent functioning fire detection, and an inadequate alternative escape route in maisonettes place residents at significant risk of …	London London (East)	Local Government Association London Borough of Barking & … London Councils National Fire Chiefs	0/8
21 Dec 2018	Mihaela Lazar 2018-0403-wp26468 · Shirley Radcliffe Inadequate fire detection and warning systems, including missing smoke alarms and kitchen doors, combined with unacceptable escape routes in older maisonettes, pose …	London London (East)	National Fire Chiefs	0/1
21 Dec 2018	Cady Stewart 2018-0402 · Alison Mutch Opiate medication from a deceased parent on palliative care was not removed by nursing staff, remaining accessible and subsequently used by the …	North West Manchester (South)	Tameside Clinical Commissioning Group	0/1