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 |
|---|---|---|
| 1 Aug 2018 |
Cuthbert Hingert
2018-0280 · Caroline Sumeray
Significant medication errors, including duplicate prescribing and incorrect dosages, occurred due to clinicians failing to check databases and insufficient training. A nurse …
|
0/1 |
| 6 Aug 2018 |
Susan Elliott
2018-0275 · Derek Winter
An X-ray report was ignored and no CT scan performed before discharge, leading to decisions based on clinical impression without a definitive …
|
1/1 |
| 8 Aug 2018 |
Keith Dransfield
2018-0273 · David Urpeth
An inappropriate observation regime without justification, lack of clear risk assessments, and staff failing to consult patient records, alongside insufficient training, contributed …
|
1/1 |
| 8 Aug 2018 |
Ian Wolstenholme
2018-0272 · Lisa Hashmi
A lack of national guidance for clinicians on co-prescribing multiple highly addictive and potentially harmful drugs creates a risk of serious harm …
|
1/2 |
| 27 Jul 2018 |
Natalie Billingham
2018-0274 · Zafar Siddique
Inadequate communication, delayed assessment of blood results, and missed opportunities for early antibiotic administration led to a failure in recognising the development …
|
0/2 |
| 9 Aug 2018 |
Kelly Campbell
2018-0271 · Caroline Beasley-Murray
Concerns exist regarding the lack of rigorous trust policies for returning items like shoelaces and the dreary, unstimulating physical environment in patient …
|
0/1 |
| 9 Aug 2018 |
Aditya Puri
2018-0268 · Rachel Syed
Specific matters of concern regarding the prevention of future deaths were not detailed in the provided text.
|
1/2 |
| 8 Aug 2018 |
Donald Clegg
2018-0269 · Lisa Hashmi
Insufficient care transfers, inadequate pre-admission assessments, and unsafe medicine administration processes, coupled with staff's inability to recognise deteriorating patients and poor record …
|
2/2 |
| 7 Aug 2018 |
Steven Welch
2018-0267 · Sarah-Jane Richard
Errors in assessing head injury urgency and significant delays in transferring patients to neurosurgical centers, compounded by a lack of specialist radiologists …
|
2/4 |
| 4 Oct 2018 |
Bradley Morgan
2018-0412 · Emma Brown
Mental health services suffered communication breakdowns and severe underfunding, resulting in excessive staff caseloads and a lack of timely patient follow-up, which …
|
2/2 |
| 16 Oct 2018 |
Jacqueline Oakes
2018-0419 · Louise Hunt
There is no system to alert other agencies when high-risk offenders are released after completing their full sentence, preventing effective risk management.
|
1/2 |
| 11 Oct 2018 |
Thomas Lear
Margaret Jones
A released prisoner was offered no accommodation support, and urgent suicide threats sent to his offender manager's mobile went unaddressed due to …
|
0/2 |
| 11 Oct 2018 |
Dean Barrell
James Healy-Pratt
A seven-day delay in communicating a vulnerable prisoner's actual release date to HMP Lewes contributed to his suicide, highlighting unacceptable communication delays …
|
1/1 |
| 13 Aug 2018 |
Kamal Al-Hirsi
2018-0265 · ME Hassell
Dangerous pool cleaning methods, inadequate staff water safety training, ineffective panic alarm systems, and flawed emergency communication protocols highlight significant safety failures …
|
1/1 |
| 8 Oct 2018 |
Natasha Ednan-Laperouse
2018-0279 · Sean Cummings
Allergens were not adequately labelled on Pret-a-Manger packaging, and there was no coordinated system for monitoring customer allergic reactions. Additionally, the needle …
|
2/4 |
| 4 Oct 2018 |
Michael Cooper
2018-0413 · Emma Brown
Chronic underfunding of mental health services led to a critical lack of inpatient beds and excessive Care Coordinator caseloads, causing delayed follow-ups …
|
2/2 |
| 13 Aug 2018 |
Stephen Lawson
2018-0264 · Ian Pears
The car park has a history of suicides and easy access to the external barrier wall. There are also very few visible …
|
1/1 |
| 24 Aug 2018 |
Jacqueline Jordan
2018-0263 · Maria Voisin
The absence of a central reservation barrier along a specific stretch of dual carriageway allows pedestrian shortcuts, posing a significant risk to …
|
1/1 |
| 1 Oct 2018 |
Hayley Gascoigne
Paul Marks
The Hull Combined Court Centre lacked a defibrillator, despite expert opinion that all public buildings should be equipped with such apparatus to …
|
1/2 |
| 26 Sep 2018 |
Angela Jackson
Alan Walsh
A critical absence of clear, documented national and regional pathways for aortic aneurysm referrals, including correct hospital names and contact details, leads …
|
2/4 |