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 |
|---|---|---|
| 7 Jun 2018 |
Kevin Freely
2018-0180 · Sarah Ormond-Walshe
Insufficient awareness and adherence to fire safety warnings regarding paraffin-based emollients, smoking in bed, and air-flow mattresses, combined with inadequate risk assessments, …
|
0/3 |
| 15 Jun 2018 |
Darren Carrington
2018-0181 · Veronica Hamilton-Deeley
The report is incomplete and does not contain any specific concerns from the coroner.
|
3/2 |
| 15 Jun 2018 |
Sneh Chaudhry
2018-0182 · Sean Cummings
Drug confusion due to similar vial appearance between Fungizone and Ambisone, combined with passive nursing checks, created a risk of administering the …
|
0/1 |
| 6 Jun 2018 |
Ester Wood
2018-0176 · David Pojur
Ongoing, systemic problems with ambulance delays, emergency department access, and patient flow continue to place lives at risk, despite repeated prior warnings.
|
0/4 |
| 19 Jun 2018 |
Patricia Palin
2018-0183 · Heath Westerman
Healthcare providers lacked access to GP records, A&E was understaffed, essential medication administration was delayed, and red flag signs of sepsis were …
|
1/2 |
| 18 Jun 2018 |
Bryan Allsop
2018-0185 · Peter Nieto
Pilot licensing does not mandate instruction and testing in partial engine power loss scenarios for light aircraft, despite this being a common …
|
0/1 |
| 19 Jun 2018 |
Andrew Hanahoe
2018-0184 · Ian Pears
A railway foot crossing lacked adequate safety measures, including proper fencing, warning lights, or trespass deterrence, despite high-speed trains, posing a significant …
|
1/1 |
| 13 Jun 2018 |
Karen Wiggins
2018-0177 · Nicholas Rheinberg
Multi-storey car parks in Swindon lack physical barriers or warning notices, despite previous suicidal falls, failing to prevent individuals from jumping.
|
0/1 |
| 28 Mar 2018 |
Donald Martin
2018-0166 · Anna Crawford
A nurse lacked essential knowledge regarding appropriate CPR on flat surfaces and how to deflate patient mattresses during emergencies, posing a risk …
|
1/2 |
| 6 Jun 2018 |
William Bartram
2018-0174 · Nadia Persaud
Unclear processes for repeat blood samples in babies, failure to highlight abnormal test results, and inadequate discharge advice to parents led to …
|
0/1 |
| 7 Jun 2018 |
Marcus Hance
2018-0173 · Guy Davies
The dual diagnosis policy, requiring substance misuse treatment before mental health support, and discharge from services after missed appointments, prevented access to …
|
1/2 |
| 5 Jun 2018 |
Rosemary Scott
2018-0172 · Brendan Allen
Failure to measure venous blood gases due to a missing reminder system for the Sepsis Six Pathway, and an insufficient number of …
|
1/1 |
| 4 Jun 2018 |
John Derwent
2018-0171 · Alison Mutch
Excessive waiting times for CBT (12 months) due to insufficient capacity and ineffective escalation mechanisms between commissioning and service providers prevented timely …
|
0/2 |
| 1 Jun 2018 |
Imtiaz Mohammed
2018-0170 · Louise Hunt
Excessive speed, defective tyres, driving under the influence of cannabis, and non-use of seatbelts resulted in a fatal multi-vehicle collision.
|
1/2 |
| 31 May 2018 |
Elaine Horrocks
2018-0169 · John Pollard
Unsafe access methods to the cellar and insufficient guarding of cellar steps against accidental public entry pose a safety risk.
|
0/2 |
| 29 May 2018 |
George Dyson
2018-0168 · Martin Fleming
The urgent need to review and implement protective safety measures on North Bridge to prevent further fatalities, following previous similar incidents.
|
1/1 |
| 20 May 2018 |
Mwitumwa Ngenda
2018-0167 · Martin Fleming
Concerns focus on the urgent need for preventative measures and design changes on Scammonden Bridge to prevent future suicide attempts.
|
0/1 |
| 21 May 2018 |
Michalla Sweeting
2018-0165 · Maria Voisin
Concerns were raised about inadequate handover procedures for detox patients, including nurses' record review responsibilities and the timing of observations relative to …
|
0/1 |
| 29 May 2018 |
Joan Lunt
2018-0164 · Chris Morris
Deficiencies in electronic record-keeping by agency staff, including unidentified entries, compromise record integrity and continuity of care, despite prior assurances of resolution.
|
0/1 |
| 25 May 2018 |
Neil Jones
2018-0163 · Sean McGovern
Repeated fatal road traffic collisions at a specific site, despite speed limit reduction, highlight the urgent need for a determined casualty reduction …
|
1/1 |