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 209 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
19 Apr 2018	Amanda Spark 2018-0109 · Rachael Griffin Concerns arose regarding a patient's decision to change her medication regime while under crisis team care, implying potential issues with medication management …	South West Dorset	Dorset University NHS Trust	0/1
18 Apr 2018	Harry Jellicoe 2018-0108 · Paul Smith The national speed limit is too high for a bridge with restricted visibility and a height limitation requiring high-sided vehicles to use …	East Midlands Lincolnshire	Lincolnshire County Council	0/1
17 Apr 2018	Matthew Wilmot 2018-0107 · Ian Pears Risk assessments for path closures are inadequate for unique routes without alternative access, leading pedestrians to disregard barriers and use hazardous excavations.	East of England Bedfordshire and Luton	B & D Civil Engineering … M & S Water Services	2/2
16 Apr 2018	Karen Edgar 2018-0106 · David Roberts Critically underfunded child and adolescent mental health services in Cumbria result in long treatment delays, risking lives and causing lasting harm.	North West Cumbria	Cumbria Partnership NHS Foundation Trust Department of Health and Social … Morecambe Bay Clinical Commissioning Group North Cumbria Clinical Commissioning Group	1/4
12 Apr 2018	William Callis 2018-0105 · Anne Pember A lack of clear, specific instructions for GP practices on how to refer to the Urgent Care and Assessment team was identified.	East Midlands Northamptonshire	St Lukes Primary Care Centre	0/1
11 Apr 2018	George Goldby 2018-0104 · Jane Gillespie Nursing home staff were unaware of and failed to adhere to SALT recommendations for supervision and diet, resulting in missed re-referral opportunities …	East Midlands Nottinghamshire	HC-One	1/1
12 Apr 2018	Patricia Heslop 2018-0102 · Derek Winter Failures in care home included unreported falls, poor record-keeping, un-updated care plans, and staff inadequately trained in recognising patient deterioration and dementia …	North East Sunderland	Department of Health and Social … HC-One	2/2
10 Apr 2018	Lea Hunsley 2018-0101 · Lisa Hashmi The care facility lacked an SUI protocol, and staff demonstrated inadequate skills in identifying and escalating deteriorating patients, poor observation, and insufficient …	North West Manchester (North)	EAM Care Group	1/1
5 Mar 2018	Mike Fell 2018-0100 · Sarah Bourke Unused trauma lines lack a clear mechanism and documentation for ensuring they are "closed to air," with some lines lacking essential clamps, …	London London Inner (North)	Barts Health NHS Trust Royal College of Anaesthetists	2/2
9 Apr 2018	Naseeb Chuhan 2018-0099 · Jonathan Leach Payday loan companies contributed to the deceased's dependency by encouraging loans despite awareness, and their financial checks were inadequate.	Yorkshire and the Humber West Yorkshire (East)	Financial Conduct Authority	1/1
9 Apr 2018	Darryl Souza 2018-0098 · Hassan Shah Compromised visibility at a crossroads junction, despite existing signage, necessitates urgent improvements like renewed signs, rumble strips, and "Stop" signs, but these …	East Midlands Northamptonshire	National Highways Northamptonshire County Council Northamptonshire Highways	1/3
29 Mar 2018	Matthew Faulkner 2018-0097 · Geoffrey Sullivan Emergency ambulance services face severe resource shortages, unsustainable demand, and significant hospital handover delays, reducing ambulance availability for emergency calls.	East of England Hertfordshire	East of England Ambulance Service Lister Hospital Luton and Dunstable Hospital Princess Alexander Hospital	4/4
6 Apr 2018	Miriam Roach 2018-0096 · Guy Davies There are concerns regarding the aftercare or transition arrangements for those discharged from hospital to home with a moderate to high risk …	South West Cornwall and the Isles of Scilly	NHS Kernov Clinical Commissioning Group	0/1
3 Apr 2018	Barbara Haley 2018-0095 · Rachel Galloway Staff provided unsuitable food to a high-risk choking patient on a soft diet and left her unsupervised during meals, contrary to safety …	North West Manchester (South)	Care Quality Commission Harbour Healthcare Hilltop Court	0/3
3 Apr 2018	Casper Blackburn 2018-0094 · 2018-0094 Extremely poor lighting and lack of CCTV near the canal made it difficult to discern the water from the land at night, …	North West Manchester (South)	Canals and Waterways Agency Peel Holdings Trafford County Council	1/3
29 Mar 2018	Ross Reeves 2018-0093 · Veronica Hamilton-Deeley The patient's transfer to his new GP was identified as likely unsafe.	South East Brighton and Hove	Brighton and Hove Clinical Commission … British Medical Association NHS England	1/3
27 Mar 2018	Matthew Gayle 2018-0092 · Andrew Haigh Insufficient numbers of consultant histopathologists and a lack of compulsory training in coroner's autopsies risk incomplete death investigations, as exemplified by a …	West Midlands Staffordshire (South)	Department of Health and Social …	0/1
26 Mar 2018	Joan Osborne 2018-0091 · Jane Gillespie Numerous failures in nursing home care included not seeking specialist advice, missing appointments, inadequate record-keeping, and poor recognition/response to deteriorating patient condition …	East Midlands Nottinghamshire	Adbolton Hall Nursing Home	1/1
27 Mar 2018	Maureen Campbell-Scott 2018-0090 · Nadia Persaud A referral was sent to the wrong team and then lost, causing a four-month delay in assessment. There were also delays in …	London London (East)	North East London Trust Fullwell Cross Medical Centre	1/2
28 Mar 2018	John Wherlock 2018-0089 · Robert Sowersby Simultaneous staff breaks led to insufficient ward cover and unsupervised patients, directly resulting in a fall; this unsafe staffing practice was still …	South West Avon	Bristol NHS Trust	0/1