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 200 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
21 Dec 2018	Diane Greenslade 2018-0401 · Wendy James Inadequate ambulance call categorisation without clinical assessment, failure to escalate after failed contact, and high demand compounded by hospital delays led to …	Wales Gwent	Aneurin Bevan University Health Board Welsh Ambulance Services	2/2
21 Dec 2018	William Atherton 2018-0400 · Yvonne Blake Failure of medical review, unrecognised worsening condition, missing nursing observations, and incorrect, inconsistently applied Early Warning Scores prevented proper escalation of patient …	East of England Norfolk	Queen Elizabeth Hospital	0/1
21 Dec 2018	Paul Fairey 2018-0399 · Philip Barlow Obscured street lighting, faded road markings, and an ineffective speed cushion created hazardous road conditions, compromising pedestrian and motorist safety.	London London Inner (South)	London Borough of Lewisham	1/1
20 Dec 2018	Maria Hryniw 2018-0398 · Alison Mutch Lack of assessment for PEG feeding suitability/volume for an end-of-life patient, unaddressed family concerns, and poor understanding between healthcare teams regarding decision-making, …	North West Manchester (South)	Care Quality Commission Department of Health and Social …	2/2
19 Dec 2018	Kurt Cochran; Leslie Rhodes; Aysha Frade; Andreea Cristea; PC … 2018-0304 · HH Judge Mark Lucraft QC A Prevention of Future Deaths report was issued to multiple authorities following the Westminster terror attack to address systemic issues related to …	London London Inner (West)	Department for Transport Home Office Metropolitan Police Speaker’s Counsel, for the attention …	7/8
4 Oct 2018	Simon Graham 2018-0418 · Emma Brown Respite home had critical safety failures including lone working delaying emergency response, incorrect room labelling impeding access, and unqualified staff conducting suicide …	West Midlands Birmingham and Solihull	Birmingham Clinical Commissioning Group Future Care & Social Care … NHS England	2/3
4 Oct 2018	William Edge 2018-0417 · Emma Brown A suicidal patient was discharged without adequate follow-up from the Home Treatment Team, who could not revisit despite an urgent family request, …	West Midlands Birmingham and Solihull	Birmingham Clinical Commissioning Group NHS England	2/2
4 Oct 2018	Stephen Jackson 2018-0416 · Emma Brown Mental health services failed to provide essential post-discharge follow-up from the home treatment team despite an urgent GP referral, leaving the patient …	West Midlands Birmingham and Solihull	Birmingham Clinical Commissioning Group NHS England	2/2
17 Dec 2018	Agnes Lambert 2018-0410 · ME Hassell Senior staff failed to ensure a nurse's ward transfer despite patient fixation concerns, leading to an incident. The trust also caused distress …	London London Inner (North)	Camden & Islington NHS Trust	1/1
26 Nov 2018	Jack Riding 2018-0303 · Joseph Hart There were significant delays in defibrillator deployment and ambulance access due to equipment placement, lack of staff direction, and insufficient emergency training, …	North West Liverpool & Wirral	Football Association Goals Soccer Centres PLC	1/2
11 Dec 2018	Paliben Dullabh Sarah Bourke The hospital lacks arrangements for obtaining out-of-hours radiology reports for X-rays, unlike its provision for CT and MRI scans.	London London Inner (North)	Homerton Healthcare NHS Foundation Trust	1/1
4 Oct 2018	Michael Wheeler 2018-0414 · Emma Brown Inadequate mental health service funding led to a lack of psychiatrist review for a patient with severe paranoia and inpatient bed shortages, …	West Midlands Birmingham and Solihull	Birmingham Clinical Commissioning Group NHS England	2/2
28 Nov 2018	Michelle Roach 2018-0302 · Heidi Connor GP's knowledge of VTE symptoms and record-keeping were inadequate. The GP practice lacked a robust system for learning from unexpected deaths, and …	South East Berkshire	Royal Berkshire Hospital Waterfield Practice	0/2
16 Nov 2018	Eleanor Brabant 2018-0301 · Grahame Short Observation policies for vulnerable patients were unclear, staff lacked training on safeguarding and reporting crimes, and nurses misunderstood their powers to detain …	South East Southampton and New Forest	Southern Health NHS Foundation Trust	0/1
15 Nov 2018	Richard Hill Stephanie Haskey The railway crossing lacked essential telephones and Network Rail contact information, posing a risk of repeat incidents due to inadequate emergency communication …	East Midlands Nottinghamshire	Network Rail	1/1
1 Nov 2018	Stephen Taylor Andrew Cox Neurosurgical patients lacked consultant physician support, leaving junior doctors to manage complex medical issues. An unclear alcohol withdrawal protocol led to incorrect …	West Midlands Worcestershire	University Hospital Coventry and Warwickshire …	1/1
31 Oct 2018	Stephen Buck Darren Salter The common practice of operatives working in close proximity to reversing trucks for ticketing spoil removal increases safety risks, suggesting a need …	South East Oxfordshire	Waste Industry Safety & Health …	1/1
1 Aug 2018	Nigel Handscomb 2018-0278 · Philip Barlow Incomplete and inaccurate GP consultation notes, made several hours after the fact, failed to record critical patient information, including examination findings and …	London London Inner (South)	Eden Park Surgery	0/1
29 May 2018	Brian Bicat 2018-0277 · Martin Fleming Inadequate fire hazard warnings on paraffin-based emollient packaging, insufficient awareness among healthcare professionals and the public, and inconsistent prescribing system alerts pose …	Yorkshire and the Humber West Yorkshire (West)	Bradford District Care Foundation Trust Department of Health and Social … Diprobase Bayer Public Limited Medicines and Healthcare Products Regulatory …	3/6
6 Aug 2018	Phylliss Letcher 2018-0276 · Guy Davies The care home lacked live CCTV monitoring for staircases, had no key fob access control, and no alarm if the stairgate was …	South West Isles of Scilly	Crossroads House Care Home	1/1