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 210 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
28 Mar 2018	Anthony Paine 2018-0088 · Andre Rebello The provided text is a placeholder, stating that a brief summary of matters of concern will follow, but no specific concerns are …	North West Liverpool and Wirral	HM Prison and Probation Service Ministry of Justice The Chief Coroner of England …	2/3
21 Mar 2018	Edward Lundy 2018-0087 · Tony Williams Poor continuity of care, inadequate family consultation on discharge risks, and lack of evidence for implementing recommended improvements in mental health risk …	South West Somerset	South London and Maudsley NHS …	0/1
12 Mar 2018	Leigh Wilde 2018-0085 · Alison Mutch The company lacked documented rationale for employee suspension, failed to consider risk factors or offer support services, and kept inadequate meeting records, …	North West Manchester (South)	IMI (Institute of the Motor … LTE Group	0/2
9 Mar 2018	David Sketchley 2018-0069 · Caroline Saunders The investigation into a patient's death was inadequate, failing to determine supervision levels, collaborate with manufacturers, identify incident cause, or properly assess …	South West Gloucestershire	BUPA UK CARE QUALITY COMMISSION Medicines and Healthcare Products Regulations … Performance Health	1/4
7 Mar 2018	Venkata Kagga 2018-0068 · Alison Mutch Critical safety features for button batteries in household devices are lacking, and national safety alerts are not effectively sustained. Hospital policies for …	North West Manchester (South)	The Royal Society for Prevention … Healthcare Safety Investigation Branch Department of Health and Social … NHS England	1/5
6 Mar 2018	Ellie Clark 2018-0066 · Wendy James Failures in care planning, clinical oversight, and triage systems led to delayed and inadequate care. Critical medical information was not prominent, and …	Wales Gwent	Aneurin Bevan University Health Board Grange Clinic	1/2
6 Mar 2018	Rastislav Petrisko 2018-0067 · Andrew Harris Inconsistent risk assessment and classification of a patient, combined with a delayed police notification policy for absconding low-risk patients, led to an …	London London Inner (South)	Oxleas Mental Health Trust	0/1
22 Mar 2018	Kenneth Longley 2018-0086 · Rachel Galloway A nearly three-month delay in sending crucial medical information to the patient's GP after an echocardiogram created a risk of future deaths …	North West Manchester (South)	Graham Street, Beswick, Manchester Wythenshawe Hospital	0/2
21 Mar 2018	Barbara Johnson 2018-0084 · Rachel Galloway Junior doctors routinely ignored diagnostic printouts from ECG machines, which flagged abnormalities, raising concerns about the impact on clinical interpretation and judgment.	North West Manchester (South)	Pennine Acute NHS Trust	2/1
19 Mar 2018	Kellie Taylor 2018-0083 · Paul Marks The poor resolution of the CCTV system hindered accurate monitoring of individuals and delayed timely intervention during potential emergencies at the bridge.	Yorkshire and the Humber East Riding and Kingston upon Hull	Humber Bridge Board	1/1
14 Mar 2018	Janet Hall 2018-0082 · Chris Morris The Emergency Department system, relying on manual transcription of blood results by junior doctors, led to incorrect discharge letters and prevented GPs …	North West Manchester (South)	Pennine Acute Hospitals NHS Trust	0/1
19 Mar 2018	Sheila Ross 2018-0081 · Derek Winter The care home used an outdated falls risk assessment, had a limited buzzer system unable to provide timely assistance, and exhibited poor …	North East Sunderland	Hylton View Care Home	0/1
15 Mar 2018	Jean Griffiths 2018-0080 · Jennifer Leaming A national audit revealed widespread poor oxygen prescribing practices in hospitals, with many patients lacking valid prescriptions, risking inappropriate oxygen levels and …	North West Manchester (West)	Department of Health and Social …	1/1
6 Mar 2018	Georgia Polydorou 2018-0079 · Sarah Bourke Elderly patients on blood thinners are at risk due to delayed CT scans after falls, as deterioration signs can be delayed. Communication …	London London Inner (North)	Homerton Healthcare NHS Foundation Trust N.I.C.E	1/2
14 Mar 2018	Freddie Dobinson-Evans 2018-0078 · ME Hassell A critical genetic test result, indicating a pathogenic mutation, was misread as normal, leading to a diagnostic error that could have significant …	London London Inner (North)	Great Ormond Street Hospital for … Barts Health NHS Trust	1/2
14 Mar 2018	Peter Stojilkovic 2018-0077 · Alison Mutch Poor communication post-discharge about melatonin prescribing and a complex, inconsistent system of national and local drug blacklists forced patients to seek medication …	North West Manchester (South)	Stockport Clinical Commissioning Group Department of Health Heaton Moor Medical Practice Mayor of Greater Manchester	1/5
14 Mar 2018	Thomas Curtin 2018-0076 · Emma Carlyon Private mental health locked rehabilitation units lack a national framework for referral response times, potentially leaving patients on inappropriate wards and risking …	South West Cornwall and the Isles of Scilly	NHS England	1/1
13 Mar 2018	Catherine Kennedy 2018-0075 · Chris Morris Miscommunication between ward staff and an on-call doctor led to a significant delay in patient review after an overdose, highlighting the lack …	North West Manchester (South)	Pennine Care NHS Trust	2/1
6 Mar 2018	William Abrahams 2018-0074 · Sarah Bourke The current AAA screening program excludes individuals over 65 at its introduction, and the "opt-in" nature for asymptomatic conditions may hinder participation, …	London London Inner (North)	NHS England	1/1
7 Mar 2018	Ivanika Olivari 2018-0073 · Fiona Wilcox Hospital guidelines and staff training are inadequate regarding urgent patient contact, specifically for leaving messages and utilising all contact numbers, risking delays …	London London Inner (West)	Department of Health and Social … General Medical Council St George's University Hospitals NHS …	2/3