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 |
|---|---|---|
| 25 Jul 2018 |
Jane Parker
2018-0243 · Alison Mutch
Care home staff had poor understanding of modified diets and lacked systems for correct food preparation and marking. There was also limited …
|
0/2 |
| 25 Jul 2018 |
Aniyah Winston
2018-0241 · Alison Mutch
Undetected breech births are common due to lack of routine pre-delivery scans, and staff felt uncomfortable challenging a clinician's decision to administer …
|
1/2 |
| 26 Jul 2018 |
Daniel Young
2018-0240 · Shirley Radcliffe
GP surgeries lack routine monitoring for psychiatric patients collecting antipsychotic medication, increasing the risk of relapse and harm to themselves or others.
|
1/1 |
| 26 Jul 2018 |
Herbert Francis
2018-0242 · Jonathan Layton
The junction lacks adequate road markings, early warning signs, and properly positioned speed limit signs. Filter lanes are too short, and there's …
|
1/2 |
| 24 Jul 2018 |
Taiyah-Grace Peebles
2018-0239 · Ian Goldup
Many railway platforms lack barriers to prevent accidental contact with live rails, which pose a significant electrocution risk compared to safer overhead …
|
1/1 |
| 19 Jul 2018 |
William Watson
2018-0237 · Andrew Cox
Ambulance services and patient transport face significant performance gaps due to insufficient funding, leading to critical delays in emergency, high dependency, and …
|
2/2 |
| 19 Jul 2018 |
Jeroen Ensink
2018-0235 · ME Hassell
Police failures included not creating mental health alerts, inaccurate record-keeping regarding injuries and force, and failing to inform the forensic medical examiner …
|
0/1 |
| 20 Jul 2018 |
Ruth Perkins
2018-0236 · Emma Whitting
A high-risk patient was discharged to a care home with insufficient staffing levels for her needs, particularly lacking 1:1 care, significantly increasing …
|
0/1 |
| 19 Jul 2018 |
Ronald Harman
2018-0234 · Veronica Hamilton-Deeley
The provided text indicates general concerns about matters revealed during the inquest, suggesting a risk of future deaths without specifying particular issues.
|
0/1 |
| 12 Jun 2018 |
Olive Nutt
2018-0233 · Russell Caller
Inaccurate recording of symptoms by the ambulance service led to an incorrect priority decision and delayed attendance, breaching internal call-back guidelines.
|
1/1 |
| 19 Jul 2018 |
Nigel Malloy
2018-0232 · Grahame Short
There was a critical lack of information sharing and coordinated treatment planning between the Alcohol Liaison service and other support services for …
|
1/2 |
| 18 Jul 2018 |
Darren Neilson
2018-0231 · Louise Hunt
The tank was able to fire without the BVA assembly being present, a hazard not adequately considered during production and manufacture. There …
|
2/2 |
| 18 Jul 2018 |
Matthew Hatfield
2018-0231-wp26293 · Louise Hunt
Soldiers lacked clarity on gun safety drills, and the officer in charge lacked critical information on tank status. Risk assessments also failed …
|
2/2 |
| 18 Jul 2018 |
Mohammed Ahmed
2018-0230 · Simon Nelson
Professionals were unprepared for a live birth after feticide, which occurred due to minimised scan time for confirming fetal death. Concerns identify …
|
0/3 |
| 16 Jul 2018 |
Sheila Ridgway
2018-0229-wp26291 · Rashid Sohall
A lack of systemic communication between specialty consultants prevents identifying and documenting potential ongoing risks when patients receive simultaneous treatments from different …
|
0/5 |
| 17 Jul 2018 |
Leslie Bingham
2018-0228 · Christopher Dorries
Pedestrians approaching a road from one direction may be misled by a green light intended for pedestrians crossing from a different direction.
|
1/1 |
| 16 Jul 2018 |
Tyrone Evans
2018-0227 · Emma Whitting
There is no legal requirement for quad bike riders to wear crash helmets, even on road-adapted vehicles, despite evidence suggesting a helmet …
|
1/2 |
| 12 Jul 2018 |
Adam Carter
2018-0226 · Alan Wilson
Poor record-keeping for a detained mental health patient meant risks, leave rationale, and assessments were undocumented, hindering informed decision-making and continuity of …
|
1/1 |
| 12 Jun 2018 |
Rita Taylor
2018-0225 · Karen Henderson
Inadequate management of hyponatraemia, including a consultant's failure to seek expert advice and non-adherence to national guidelines, resulted in a lack of …
|
1/3 |
| 11 Jul 2018 |
Rita Giles
2018-0224 · Veronica Hamilton-Deeley
The provided text indicates general concerns about matters revealed during the inquest, suggesting a risk of future deaths without specifying particular issues.
|
0/4 |