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 207 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
23 May 2018	Grahame Searby 2018-0162 · Martin Fleming The mental health team's lack of access to GP databases (EMIS) hinders comprehensive information gathering, necessitating a review of operational systems to …	Yorkshire and the Humber West Yorkshire (West)	South West Yorkshire NHS Trust	0/1
9 May 2018	Lewis Colgan 2018-0161 · Crispin Butler Inadequate supervision of care coordinators, incompatible caseloads, and staff changes compromised mental health care continuity and engagement. Lack of robust processes for …	South East Buckinghamshire	Oxford Health NHS Trust	0/1
24 May 2018	Rosalind Flett 2018-0160 · Selena Lynch Ambiguity in the Trust's search policy created a gap between "advanced" and "intimate" searches, preventing staff from conducting thorough searches and potentially …	London London (South)	Department of Health and Social …	0/1
22 May 2018	Andrew Crane 2018-0158 · Philip Barlow Unclear guidance for prison officers on initiating emergency calls for chest pain, and failure to update ambulance services with critical changes in …	East Midlands Northamptonshire	HMP Ryehill	0/1
22 May 2018	Michael Berry 2018-0157 · Ian Pears A "reduced risk" healthcare cell contained a clear ligature point, an inwardly opening window, indicating a design flaw that could be easily …	East of England Bedfordshire & Luton	HM Prison Bedford	0/1
21 May 2018	Alfie Scambler-Holt 2018-0156 · Alison Mutch The absence of a national PEWS scoring system creates inconsistency across trusts, leading to varied escalation processes and potential risks for children …	North West Manchester (South)	NHS England Secretary of State for Health	0/2
21 May 2018	Caroline Scott 2018-0155 · Thomas Osborne Out-of-hours emergency mental health services are inadequate, and medical staff do not fully understand the emergency referral policy.	South East Milton Keynes	Central and North West London …	0/1
21 May 2018	Carter Jepson 2018-0154 · Alison Mutch A critical gap exists in providing medication to suppress lactation for breastfeeding mothers after infant loss, intensifying psychological distress due to continued …	North West Manchester (South)	Department of Health and Social …	1/1
18 May 2018	Graeme Mathieson 2018-0153 · Andrew Cox GPs face unmanageable time constraints without proper triage, and professionals are confused about mental health patient pathways, especially after incorrect discharge from …	South West Plymouth Torbay and South Devon	Devon Local Medical Committee Livewell Southwest NHS England	0/3
18 May 2018	Henry Heselton 2018-0152 · Caroline Topping Electronic mental health records were unclear, making vital history hard to access, and there was a critical lack of communication between mental …	South East Surrey	Southern Health NHS Trust	1/1
15 May 2018	Doris Ridgwell 2018-0151 · Anna Loxton A critical communication failure meant an abnormally high INR result for a Warfarin patient was not effectively relayed or acted upon before …	South East Surrey	Care Quality Commission Epsom & St Helier University …	1/2
17 May 2018	Neville Welton 2018-0150 · John Gittins The Health Board demonstrates persistent delays in completing serious incident reviews and implementing action plans, leaving safety measures outstanding for too long.	Wales North Wales (East & Central)	Betsi Cadwaladr University Health Board Ysbyty Gwynedd	1/2
14 May 2018	Gladys Rich 2018-0149 · Hassan Shah The care home failed in fall risk assessment and action plan implementation, while the under-resourced Falls Prevention Service lacked proactive follow-up and …	East Midlands Northamptonshire	Avenue House Nursing and Care … Care Quality Commission Kettering General Hospital Northamptonshire Healthcare NHS Trust	1/4
16 May 2018	Lucia Ciccioli 2018-0148 · Russell Caller Inadequate cycle lanes and protection at a junction, problematic road markings, and dangerous road conditions in an adjoining street compromise cyclist safety.	London London Inner (West)	Transport for London Wandsworth, Merton, Richmond and Sutton …	1/2
11 May 2018	Thomas Ratchford 2018-0147 · Catherine McKenna Carers improperly used a hoist for pressure relief without expert advice, highlighting insufficient training in moving/handling and pressure relief for staff and …	North West Manchester (North)	Elizabeth House (Oldham) Limited	0/1
14 May 2018	Philip Ashton 2018-0146 · Thomas Osborne Medication errors occurred due to flawed procedures, staff were unprepared for emergencies, and vital medical history was inaccessible to ambulance crews.	South East Milton Keynes	PJ Care	0/1
11 May 2018	Marcus Allen 2018-0144 · Kevin McLoughlin Large lounge windows lacking restrictor devices open excessively, creating a fall hazard when residents must lean out to close them.	Yorkshire and the Humber West Yorkshire (East)	Radcliffe Investment Properties	1/1
14 May 2018	Hans-Peter Schmidt 2018-0145 · Guy Davies Lack of barrier maintenance, absent permanent barriers, inadequate international warning signs, and insufficient staff training at cliff hot spots create significant safety …	South West Cornwall& the Isles of Scilly	Cornwall Council Heritage Attractions Ltd Lands End Resort	0/3
11 May 2018	Ahmed Tabeche 2018-0143 · Nadia Persaud Care home staff lacked a complete understanding of choking risks, and current procedures for visitors providing food are insufficient, failing to adequately …	London London (East)	Twinglobe Care Homes Limited	1/1
9 May 2018	Edward Joyce 2018-0142 · Philip Barlow A child's critical high temperature following a burn was missed by the GP and not recorded or acted upon by hospital staff, …	London London Inner (South)	Chelsea & Westminster Hospital Medical Protection Society	1/2