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 |
|---|---|---|
| 26 Sep 2018 |
John Waite
Alan Walsh
Inadequate visual observation protocols following central venous catheter removal, with only 5-minute dressing checks risking significant, rapid blood loss, compounded by a …
|
2/5 |
| 19 Sep 2018 |
Grenfell Tower
2018-0262 · Fiona Wilcox
No structured health screening programme is in place for individuals impacted by the Grenfell Tower incident, risking unaddressed future health issues.
|
0/1 |
| 29 Aug 2018 |
Henry Miller
2018-0260 · Maria Voisin
The Foreign, Commonwealth & Development Office should issue specific warnings for travellers to Colombia about participating in Yage tribal ceremonies, ensuring they …
|
1/1 |
| 30 Aug 2018 |
Michael Drewell
2018-0259 · Philip Holden
A senior clinician's critical medication advice was not followed by a junior doctor, as it wasn't on electronic notes, highlighting a dangerous …
|
1/1 |
| 30 Aug 2018 |
Daniel O’Mahony
2018-0258 · Geoffrey Sullivan
Inadequate railway anti-trespass measures, including missing gates, gaps in fencing, and unreviewed signage, increase access to railway lines and the risk of …
|
1/1 |
| 29 Aug 2018 |
David Worthington
2018-0257 · Christopher Dorries
The cycling event's risk assessment inadequately identified a hazardous location with a blind bend, failed to account for high injury potential, and …
|
1/1 |
| 24 Aug 2018 |
Karl Willis
2018-0256 · Lydia Brown
"Self-certification" for medication without GP notification allows vulnerable patients with addiction issues to obtain potentially toxic drugs like Amitriptyline unchecked, removing a …
|
1/1 |
| 23 Aug 2018 |
Patricia Cragg
2018-0255 · Andrew Cox
The radiology department lacked sufficient CT resources and staff for simultaneous emergencies, causing reporting delays, and had no internal major incident policy …
|
1/1 |
| 27 Apr 2018 |
Paul James
2018-0254 · Christopher Sutton-Mattocks
A prisoner with a serious self-harm history was permitted access to razor blades in a single cell, reflecting inadequate risk assessment and …
|
1/2 |
| 21 Aug 2018 |
Kiarah Allen
2018-0253 · Louise Hunt
Unsafe nursing and clinical staffing levels result from funding models based on 85% occupancy, leaving insufficient personnel when the unit is full …
|
1/2 |
| 6 Jul 2018 |
Jacob Sulaiman
2018-0252 · Sarah Bourke
Incomplete information sharing between different care services meant response officers lacked a full picture of the patient's condition, potentially affecting assessment and …
|
1/1 |
| 21 Aug 2018 |
Louie Bradley
2018-0261 · John Pollard
Midwives' advice encourages unsafe co-sleeping practices for fatigued mothers, risking infant death. Furthermore, critical patient information was frequently omitted from standard Trust …
|
2/1 |
| 25 Jul 2018 |
Paul Allan
2018-0251 · Russell Caller
The Community Mental Health Team inappropriately discharged a patient instead of transferring care, and failed to consult required alcohol advisory services, leading …
|
1/3 |
| 10 Jul 2018 |
Bartholomew Coleman
2018-0250 · Brendan Allen
The railway line is easily accessible from a bridge with a low wall, showing signs of frequent public use and alcohol consumption, …
|
1/1 |
| 30 Jul 2018 |
Richard Barrett
2018-0249 · Rachel Knight
Seriously underestimated ambulance demand and unrealistic A&E turnaround targets led to severe ambulance shortages. Unreliable welfare call systems and failure to involve …
|
2/3 |
| 26 Jul 2018 |
Astonn Mitchell-Male
2018-0248 · Lisa Hashmi
The Trust lacks a policy for patient medication monitoring and triangulation of information in community settings, compounded by poor and non-existent record …
|
0/1 |
| 20 Jul 2018 |
Kathleen Bamforth
2018-0247 · Martin Fleming
Concerns exist regarding current practice guidelines for clomipramine prescription, specifically the merits of routine blood screens for patients on long-term use.
|
1/1 |
| 27 Jul 2018 |
Glynn Storey
2018-0246 · Leslie Hamilton
Confusion regarding responsibility for ensuring windows meet building standards between building control and builders created a false sense of compliance.
|
1/1 |
| 17 May 2018 |
Bernard Fagg
2018-0245 · Allison Summers
Concerns exist over whether patients undergoing CT scans with contrast and subsequent nil-by-mouth procedures should receive intravenous fluids, due to potential dehydration …
|
0/1 |
| 25 Jul 2018 |
Robert Wrinch
2018-0244 · Alison Mutch
The pathology department lacked systems for tracking samples and documenting clinician communications, causing delays and unclear chronologies. Incompatible IT systems between trusts …
|
0/4 |