Pauline Margerat Bradley
Addressed to: Hull University Teaching Hospital; NHS England; NHS Humber and North Yorkshire ICB
Source · Prevention of Future Deaths
Prevention of Future Deaths Reports
Browse 6,458 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
Geoffrey Fuller
Addressed to: Department of Health and Social Care
Jacqueline O’Brien
Addressed to: Worcestershire Acute Hospitals NHS Trust
Marie Bell
Addressed to: NHS England
Johnpaul Digweed
Addressed to: HM Prison & Probation Service
Suzanne Fredericks
AI-generated concerns summaryConcerns were raised that non-specialist hospitals may not provide sufficiently up-to-date blood test results for transplant patients, impacting survival, and the processes for handling samples may need improvement.
Addressed to: Addenbrooke’s Hospital; East Suffolk and North Essex NHS Foundation Trust; NHS England
Judith Marsland
AI-generated concerns summaryThere was an error in not escalating abnormal blood results, leading to patient deterioration, and key parts of the action plan for structured cross-team handovers and named responsible clinicians are not yet implemented.
Addressed to: Tameside and Glossop Integrated Care NHS Foundation Trust
Leslie Williams
AI-generated concerns summaryLife-saving measures, specifically a defibrillator and doctor, were significantly delayed, reducing opportunities for a successful outcome, and this was reportedly the third drowning incident at the resort.
Addressed to: TUI UK
Oliver Shelley
AI-generated concerns summaryThere is a lack of a dedicated sepsis algorithm for Emergency Medical Advisors (EMAs) to use during 111/999 calls, making triage difficult, and the EMA title is misleading given their lack of medical qualifications.
Addressed to: NHS England; NHS Pathways
Glen Jay
AI-generated concerns summaryThe coroner notes that other clinics may offer Preoperative Progressive Pneumoperitoneum (PPP) to patients with a history of adhesional small bowel obstruction (ASBO), a practice a Trust now contraindicates due to the risk of inducing obstruction.
Addressed to: NHS England
Aaron Hamer
AI-generated concerns summaryThe majority of prison officers do not receive mandatory refresher training in basic life support after their initial training, which could impact emergency response.
Addressed to: Prison, Probation and Reducing Reoffending
Scott Taylor
AI-generated concerns summaryThere are a limited number of tertiary centres for treatment-resistant OCD in the UK, predominantly in London and the South East, which limits access for complex cases due to capacity, criteria, and geographical distribution.
Addressed to: Department of Health and Social Care
Nola-Reign Morgan
AI-generated concerns summaryThe coroner notes a lack of national and local guidance for antenatal fetal monitoring in suspected chorioamnionitis, insufficient staff training, and an unaddressed delay in patient transfer between wards.
Addressed to: Aneurin Bevan University Health Board; Cabinet Minister for Health and Care; Health Inspectorate Wales; National Institution for Health and Care Excellence; Royal College of Midwives; Royal College of Obstetricians and Gynaecologists
Susan Dale
AI-generated concerns summaryThe care home had inaccurate record-keeping, did not follow its falls policy regarding moving a resident with a suspected head injury, and lacked proper handover between shifts concerning resident incidents.
Addressed to: Care Quality Commission; Westfield Residential Home
Charlotte Saunders
AI-generated concerns summaryThe road layout around a busy supermarket and town centre encourages pedestrians to cross a busy ring road at an unguarded point, despite nearby controlled crossings, posing a risk of future collisions.
Addressed to: National Highways; Staffordshire County Council
Naeem Ahmed
AI-generated concerns summaryConcerns exist that other Trusts might still use practices of disposing small volumes of drugs into sharps bins without denaturation and that doctors may work excessive hours across multiple providers due to unintegrated rostering systems.
Addressed to: Department of Health and Social Care; NHS England
Graham Hollis
AI-generated concerns summaryThe Speech and Language Therapy service was unable to conduct assessments of care home residents due to staffing levels, which led to a decision to feed a resident with accepted risk without specialist assessment.
Addressed to: Staffordshire and Stoke-on-Trent Integrated Care Board; University Hospitals of Derby and Burton NHS Foundation Trust
Jacqueline Frehe
AI-generated concerns summaryThe coroner was not satisfied with the communication and documentation of patients' nil by mouth status during transfer from the emergency department to a ward, or when family provide this information. There were also concerns about ward staff questioning nil by mouth status for patients with dysphagia.
Addressed to: Addressees have not been indexed.
Julie Ley
AI-generated concerns summaryThe coroner noted a senior clinician was unaware of the need to move patients to a solid surface for effective CPR, despite receiving advanced life support training. This raises concerns about the reduced effectiveness of CPR performed on soft surfaces in hospitals.
Addressed to: Lancashire and South Cumbria NHS Foundation Trust
Barry Davies
AI-generated concerns summaryNeurological observations for Mr Davies were not performed as frequently as they should have been, and a nurse discontinued them prematurely before his second CT scan.
Addressed to: Northen Care Alliance