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.

Response tracker Organisations Advanced search

Keyword

Browse by year

Browse by region

Sort

Reports

6,386 reports · Page 204 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
9 Jul 2018	Doris McCarthy 2018-0222 · Jacqueline Devonish Concerns persist about sensor system outages failing to alert staff to falls and inadequate safeguards for residents prone to sliding in chairs.	London London (South)	Baycroft Care Homes Senior Villages	0/2
9 Jul 2018	Robert Power 2018-0221 · Katy Skerrett A patient was "lost to follow-up" for eight years after an incorrect diagnosis, highlighting a risk of future deaths if outpatient care …	South West Gloucestershire	North Bristol NHS Trust	1/1
19 Sep 2018	Paul Price Louise Hunt Critical delays in information sharing between mental health services and GPs, due to incompatible IT systems and communication failures, risk patient care …	West Midlands Birmingham and Solihull	Birmingham and Solihull Mental Health …	2/1
19 Sep 2018	Sufia Begum Louise Hunt Many doctors are unaware of the BNF mobile app, a crucial tool for identifying potential drug interactions, risking preventable deaths from unknown …	West Midlands Birmingham and Solihull	Clinical Commission Group NHS England	2/2
19 Sep 2018	Hubert Kelly Laura Nash Emergency department overcrowding leads to patients waiting in corridors without meaningful interaction or timely assessment, with waiting times frequently exceeding national standards.	West Midlands Black Country	Care Quality Commission The Dudley Group Trust Foundation …	1/2
17 Sep 2018	Mark Nicols David Urpeth Inadequate signage and lighting at a construction site made pedestrian path access unclear, risking public safety, with no indication that future similar …	Yorkshire and the Humber South Yorkshire (West)	AMEY	1/1
15 Sep 2018	Marian Grant Darren Salter Failure to prescribe VTE prophylaxis due to electronic patient record (EPR) issues and inadequate safeguards for trauma patients on non-trauma wards, coupled …	South East Oxfordshire	Oxford University Hospitals NHS Foundation …	1/1
6 Jun 2018	Carol Metcalfe 2018-0175 · Kevin McLoughlin Insufficient pedestrian safety measures on the A63 dual carriageway near Waterloo Manor Hospital pose a significant risk to those crossing.	Yorkshire and the Humber West Yorkshire (East)	Leeds City Council Highways Department	1/1
25 Aug 2018	Kenneth Brincombe Caroline Saunders Carers facilitated smoking for a high-risk patient without supervision, lacked training in fire safety assessment, and smoke detectors were not linked to …	South West Plymouth Torbay and South Devon	Devon County Council Guinness Care and Support	2/2
5 Jul 2018	David Chandler 2018-0215 · Philip Barlow An outdated and unreviewed isolation procedure from previous work led to an unsafe standard for new tasks, exacerbated by a lack of …	East Midlands Northamptonshire	Carlsberg Supply Co Ltd	1/1
4 Jul 2018	Kathleen Allen 2018-0213 · Emma Brown Inconsistent application and understanding of MEWS escalation pathways in the A&E department, with conflicting staff guidance, created a risk of inconsistent patient …	West Midlands Birmingham and Solihull	University Hospitals Birmingham NHS Trust	1/1
27 Jun 2018	Angela West 2018-0212 · Sarah Bourke High-risk surgery scheduled before a weekend led to care under reduced staffing, compounded by placement on a general ward and missing fluid …	London London Inner (North)	Barts Health NHS Trust	1/1
27 Jun 2018	Dudley Brown 2018-0211 · Sarah Bourke Misconceptions about Mental Health Act procedures, withdrawal of care without welfare checks, and delays due to weekend scheduling and information requirements hampered …	London London Inner (North)	East London NHS Trust London Borough of Hackney	1/2
29 Jun 2018	Charles Rashan 2018-0210 · ME Hassell Police training should emphasize recognizing that struggling to resist arrest can be a struggle to breathe or silent choking, and highlight the …	London London Inner (North)	Metropolitan Police Service	1/1
30 Jun 2018	Yunis Hadi 2018-0209 · Lorna Tagliavini A lack of formal first aid training, including choking response, for volunteers, absence of emergency medical equipment, and insufficient oversight for child …	London London Inner (South)	London Borough of Lambeth South London Islamic Centre The Chief Coroner The Lambeth Children Safeguarding Board	1/4
29 Jun 2018	Lindsey Tyrrell 2018-0208 · Anthony Mazzag Routine testing for toxoplasmosis was not performed on stem cell transplant patients with infection signs, and local learning needs nationwide sharing.	North West Manchester (City)	Department of Health and Social … NHS England	0/2
29 Jun 2018	Ashley Notson 2018-0207 · Peter Dean There is no legal requirement for care home carers to have first aid training or to carry mobile phones, posing a risk …	East of England Suffolk	Care Quality Commission Department of Health and Social …	0/2
29 Jun 2018	Daphne Penn 2018-0206 · Peter Dean Inadequate communication of steroid risks and family concerns, alongside prescribing errors, led to an inadvertent rapid steroid dose reduction without sufficient clinical …	East of England Suffolk	Newmarket Community Hospital Rookery Medical Centre West Suffolk Hospital	0/3
25 Jun 2018	Lauren Sandell 2018-0205 · Nadia Persaud Confusion persists regarding responsibility for vaccinating children not covered by school programs, and the optional nature of GP vaccination services means there's …	London London (East)	NHS England NHS London UK Health Security Agency	1/3
28 Jun 2018	John Worthington 2018-0204 · Margaret Jones A&E made a borderline decision not to investigate a significant head injury, and the GP failed to take full observations for persistent …	West Midlands Stoke-on-Trent & North Staffordshire	Audlem Medical Practice University Hospitals of North Midlands …	1/2