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 208 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
9 May 2018	Joan Hanratty 2018-0141 · Chris Morris The system for providing antibiotics and steroids to COPD patients on request lacks explicit advice for them to seek medical attention if …	North West Manchester (South)	Denton Medical Centre	0/1
8 May 2018	Stephen Tidey 2018-0140 · Anna Loxton Inadequate recording of changes in suicide risk assessments and significant delays by mental health services in acting on high-risk MASH referrals following …	South East Surrey	Surrey & Borders Partnership NHS … Surrey County Council Surrey Police	2/3
9 May 2018	Kirsty Tolley 2018-0139 · Jacqueline Lake Inconsistent blood test monitoring for anaemia and inadequate Early Warning Score (EWS) assessment and escalation to doctors led to missed opportunities for …	East of England Norfolk	Queens Elizabeth Hospital NHS Trust	1/1
8 May 2018	Darren Trewin 2018-0138 · John Tomalin A partially blocked road drain caused water to cascade across the carriageway, and inadequate safety barriers failed to prevent a vehicle from …	South West Exeter and Greater Devon	Devon Highways	1/1
8 May 2018	William Dickens 2018-0137 · Henrietta Hill QC Hospital observation protocols for high-risk patients were not followed, and observation logs were retrospectively falsified, compromising patient safety and preventing timely intervention.	London London Inner (South)	South London & Maudsley NHS … The Care Quality Commission	1/2
27 Apr 2018	Katy Roberts 2018-0136 · L Tagliavini There was a failure to communicate the Care Plan and changes to it in writing, as well as to provide a clear …	London London Inner (South)	South London & Maudsley NHS … Southwark Safeguarding Children Board Steel & Shamash Solicitors	1/3
8 May 2018	Jonathan Earp 2018-0135 · Caroline Saunders Inadequate management of prescribed Fentanyl patches meant 'unspent' medication was not accounted for, and staff failed to consider the cumulative effect of …	South West Gloucestershire	Gloucestershire Hospitals NHS Trust	1/1
8 May 2018	Joanne Richardson 2018-0134 · Rachael Griffith Critical communication failures between mental health services meant a high-risk assessment by one team was not shared with the Community Mental Health …	South West Dorset	Dorset Healthcare University Hospital NHS …	1/1
28 Apr 2018	Sara Moran 2018-0133 · Alan Wilson Excessive caseloads for mental health professionals risk individuals not receiving adequate attention, potentially leading to fatal outcomes for vulnerable service users.	North West Blackpool & Fylde	Department of Health and Social …	1/1
28 Apr 2018	Catherine Burns 2018-0132 · Alan Wilson Emergency Department staff were overwhelmed by excessive patient numbers, leading to delays in doctor assessment and undetected patient deterioration, creating a risk …	North West Blackpool & Fylde	Blackpool Teaching Hospitals NHS Trust	1/1
3 May 2018	Kenneth Horne 2018-0131 · Margaret Jones Critical information about recent falls was omitted from discharge paperwork and not communicated during hospital transfer, potentially leading to an unsafe transfer …	West Midlands Stoke-on-Trent & North Staffordshire	Staffordshire & Stoke-on-Trent Partnership NHS … Leek Moorlands Hospital Royal Stoke University Hospital	1/3
3 May 2018	Martin Baker 2018-0130 · Andrew Cox Poor communication with the family and a shortage of care coordinators meant the patient lacked advocacy, and his family was unprepared for …	South West Plymouth, Torbay and South Devon	Livewell South West	1/1
12 Sep 2018	Greg Hutchins 2018-0129 · Sean McGovern Mental health telephone triage was undocumented and unrecorded, with no system for rapid information sharing for out-of-area patients, indicating significant gaps in …	West Midlands Warwickshire	Birmingham & Solihull Mental Health …	0/1
30 Apr 2018	Matthew Fulleylove 2018-0128 · Kevin McLoughlin Operatives have restricted space to work near metal support legs, creating a risk of fatal injuries from rotating industrial saws. Some safety …	Yorkshire and the Humber West Yorkshire (East)	Treanor Pujol Limited	0/1
1 May 2018	Christine Withers 2018-0127 · Zafar Siddique Crucial repeat blood tests for potassium levels were not performed as recommended, and nursing staff failed to adequately communicate with family about …	West Midlands Black Country	Dudley NHS Trust	1/1
25 May 2018	Robin Richards 2018-0126 · Tony Williams A shortage of suitable supported accommodation, coupled with poor communication, inadequate discharge planning, and insufficient risk assessment processes, compromised care for an …	South West Somerset	Department of Health and Social … Somerset NHS Trust	0/2
7 Mar 2018	Elizabeth Griffin 2018-0072 · Fiona Wilcox No specific concerns for future deaths were detailed in the provided text.	London London Inner (West)	Chartered Trading Standards Institute Wandsworth Watch Alarm Office for Product Safety and … Wandsworth Borough Council	3/5
20 Apr 2018	Novia Delima 2018-0112 · Alison Mutch Emergency Department demand prevented meeting triage targets, early paediatrician involvement for very young children was not ensured, and on-call consultants were not …	North West Manchester (South)	Department of Health and Social … Mayor of Greater Manchester NHS England	0/3
19 Apr 2018	Adrian Jennings 2018-0111 · Alison Mutch Disjointed IT systems, lack of joined-up discharge planning, uncommissioned support services, and limitations in a national IT system hindered effective information sharing …	North West Manchester (South)	Pennine Care NHS Trust NHS England Tameside Clinical Commissioning Group Tameside General Hospital	3/5
19 Apr 2018	Stanley Langdon 2018-0110 · Oliver Longstaff A day care centre provided services without receiving or creating an adequate care plan based on a needs assessment or family discussion, …	North East County Durham and Darlington	Durham County Council Haven Day Care Centre	1/2