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 205 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
18 Jun 2018	Colin Johns 2018-0203 · Zafar Siddique There was inadequate communication and history-taking during mental health assessments, failing to record critical self-harm attempts, and insufficient effort to find a …	West Midlands Black Country	Black Country NHS Foundation Trust Care Quality Commission	0/2
18 Jul 2018	Ellie Knowles 2018-0202 · Karen Dilks A venue maintains a license for high-risk events but lacks a robust internal protocol requiring consultation with police and council licensing officers …	North East Newcastle Upon Tyne	Hoults Limited Shindig Events Limited	0/2
30 Jul 2018	Stanford Bell Martin Fleming Concerns exist over Airedale Hospital's discharge procedures for head injury patients lacking discharge papers and Riverview Care Home's referral procedures for patients …	Yorkshire and the Humber West Yorkshire (West)	Airedale NHS Foundation Trust Riverview Nursing Home	2/2
10 Jul 2018	Eugeniusz Niedziolko David Ridley Police lacked appropriate options for managing a heavily intoxicated individual, leading to them being left alone in a public lavatory on a …	South West Wiltshire and Swindon	Dyfed & Powys Police Wiltshire Police College of Policing Council of Chief Police Officers	0/7
25 Jun 2018	William Lugg 2018-0200 · Heather Williams QC Poor understanding and non-compliance with failed visits procedures, inadequate record-keeping for keyholders, and insufficient guidance on involving police in welfare checks were …	London London Inner (North)	Careworld London Limited Tower Hamlets Borough Council	2/2
26 Jun 2018	Angela Turner 2018-0199 · Simon Nelson The response to an NHS 111 call was deemed wholly inadequate, raising concerns about emergency access to care.	North West Manchester (West)	Department of Health and Social …	1/1
25 Jun 2018	Margaret Stemp 2018-0198 · Penelope Schofield Insufficient ambulance resources led to vulnerable patients being left for hours, a lack of clinical oversight in standing down ambulances, and call-takers …	South East West Sussex	South East Coast Ambulance Services	1/1
26 Jun 2018	Margaret Evans 2018-0197 · John Gittins Persistent issues with ambulance delays, emergency department overcrowding, and resource availability continue to pose significant risks to patient safety.	Wales North Wales (East and Central)	BCUHB HM Stanley Site Welsh Ambulance Service NHS Trust Ysbyty Gwynedd	0/4
25 Jun 2018	Marjorie McMahon 2018-0196 · Rachel Galloway Significant ambulance response delays occurred for a high-priority patient due to high demand and insufficient resources, far exceeding the guideline response time.	North West Manchester (South)	Department of Health and Social … NHS England	0/2
25 Jun 2018	John Hill 2018-0195 · Rachael Griffin Firearms licensing checks failed to include crucial enquiries with family members, missing vital information about the applicant's suicidal intentions before a certificate …	South West Dorset	Dorset Police Home Office	3/2
25 Jun 2018	Andrew Craig 2018-0194 · Rachael Griffin Illicit prescription drug transfer in prison is facilitated by chaotic medication dispensing, lack of swallowing checks, and an ongoing drug problem despite …	South West Dorset	Care UK HMP Guys Marsh HM Prisons and Probation Service	2/3
22 Jun 2018	Alexia Walenkaki 2018-0193 · ME Hassell Organisational failures, including the use of inappropriate wood in equipment and a lack of accountability for annual inspections due to unclear role …	London London Inner (North)	Tower Hamlets Borough Council	0/1
22 Jun 2018	Graham Fox 2018-0192 · Robert Sowersby Junior nursing staff misunderstood that clinical responses under the NEWS system were mandatory, believing discretion could be applied, despite additional training.	South West Avon	University Hospitals Bristol NHS Trust	1/1
22 Jun 2018	Samuel Clarke 2018-0191 · ME Hassell Site security was inadequate, with an accessible turnstile allowing unauthorised entry, and a lack of contingency plans or improved equipment for security …	London London Inner (North)	Canary Wharf Group PLC	1/1
14 Jun 2018	Alfred Meek 2018-0190 · Sarah Slater Poor compliance with enhanced care supervision policies, missed daily assessments, and a lack of action on ward staff concerns about resource shortages …	Yorkshire and the Humber South Yorkshire (East)	Doncaster and Bassetlaw NHS Trust Department of Health and Social … Secretary of State for Health	1/3
21 Jun 2018	John Hazlewood 2018-0189 · Lydia Brown On-call psychiatry doctors lacked remote access to medical records, family members were not routinely involved in care planning, and frontline staff received …	East Midlands Leicester City and Leicestershire South	Leicestershire NHS Trust University Hospitals Leicester NHS Trust	2/2
22 Jun 2018	David Travers 2018-0188 · Stephen Covell It is too easy for individuals to obtain multiple prescriptions by visiting different GP surgeries, which facilitates drug abuse and the illicit …	South West Plymouth Torbay and South Devon	Devon Local Medical Committee NHS Northern Eastern and Western …	1/2
19 Jun 2018	Jacob Brown 2018-0187 · Andrew Haigh There is a concern that not mandating 'black boxes' in young drivers' vehicles, which monitor driving actions, misses a significant opportunity to …	West Midlands Staffordshire (South)	Department for Transport	1/1
19 Jun 2018	Derek Smith 2018-0186 · Andrew Haigh Poor communication between the District Nursing team, family members, and other agencies, alongside issues with nursing record availability, hindered patient care and …	West Midlands Staffordshire (South)	Virgin Care Services Limited	0/1
13 Jun 2018	Keiron Bould 2018-0178 · Louise Hunt Lack of clear communication protocols between police forces regarding incident primacy and case transfers led to significant delays in handling a missing …	West Midlands Birmingham and Solihull	National Police Chiefs' Council Warwickshire Police West Midlands Police	1/3