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 |
|---|---|---|
| 12 Mar 2018 |
Martin Tilley
2018-0071 · Caroline Saunders
A psychiatric patient with severe suicidal ideation and hallucinations was not followed up by the Homeless Healthcare Team after missing an appointment, …
|
0/1 |
| 8 Mar 2018 |
Bernard Gerrard
2018-0070 · Rachel Syed
Emergency ambulance services are experiencing unacceptable delays in vehicle response times, even for urgent calls, due to insufficient funding and overwhelming demand.
|
1/2 |
| 1 Mar 2018 |
Cyril Anderton
2018-0065 · Sean McGovern
Medical staff failed to attempt CPR due to a critical error, consulting and acting upon the wrong set of patient medical notes.
|
0/1 |
| 2 Mar 2018 |
Emily Hartley
2018-0063 · David Hinchliff
Prison was not the appropriate environment for someone with the deceased's mental health problems, and there is a need for secure, therapeutic …
|
1/2 |
| 1 Mar 2018 |
George French-Russell
2018-0062 · Alison Mutch
Inadequate information sharing and unstructured communication between EMAS and hospital staff, combined with paramedics lacking experience and support for complex obstetric emergencies, …
|
3/4 |
| 5 Feb 2018 |
Michael Spencer
2018-0032 · Alexander Forrest
A specific drug (Andexanet alfa) to reverse potentially fatal bleeding caused by Factor Xa inhibitor anticoagulants is not available in the UK, …
|
0/1 |
| 29 Jan 2018 |
Michael Vukovic
2018-0031 · Philip Barlow
The patient was discharged from psychiatric admission without follow-up, as the Home Treatment Team never saw him and a referral to a …
|
1/1 |
| 24 Jan 2018 |
Ronald Compson
2018-0030 · Zafar Siddique
Concerns included a possible system failure to contact a doctor, poor record-keeping regarding vomiting incidents, and inadequate communication with the family about …
|
1/1 |
| 24 Jan 2018 |
Lakhminder Kaur
2018-0029 · Zafar Siddique
Concerns arose regarding unmanaged long-term zopiclone addiction and the immediate cessation of the drug, which was done to prevent serious self-harm.
|
0/2 |
| 31 Jan 2018 |
Aaron Nordass-Lacey
2018-0028 · Rachael Griffin
Excessive vehicle speeds, inadequate pedestrian barriers, and confusing cycle lane signage contribute to dangerous road crossing practices by pedestrians and cyclists on …
|
1/1 |
| 27 Feb 2018 |
Adrian King
2018-0061 · Andrew Haigh
British consulate/embassy communication channels were inadequate and unresponsive to family attempts to assist with medical treatment for an ill British national abroad, …
|
1/1 |
| 28 Feb 2018 |
Andrea McHugh
2018-0060 · Anne Pember
Waivers for recreational water activities fail to disclose risks for participants with epilepsy or gather essential past medical history, compromising safety for …
|
1/2 |
| 27 Feb 2018 |
Raymond Davidson
2018-0059 · Derek Winter
Persistent operational staff shortages and overwhelming demand are causing severe and unacceptable ambulance response delays. Additionally, telephone contact not directly with the …
|
0/1 |
| 26 Feb 2018 |
Kay Morrison
2018-0058 · Christopher Dorries
There is an insufficient system for collating appropriate antibiotic history, potentially across many hospitals, and a lack of clear requirements for Trusts …
|
0/2 |
| 27 Feb 2018 |
David Ireland
2018-0057 · Lydia Brown
The crisis team failed to advise that presenting at the emergency department was an option for urgent mental health assessment, and the …
|
1/1 |
| 22 Feb 2018 |
James Quinton
2018-0056 · Nicola Mundy
Poor nursing documentation and observation charts hindered clinical oversight. A critical medication was incorrectly administered due to a verbal prescription, highlighting a …
|
1/1 |
| 22 Feb 2018 |
Christopher Brookes
2018-0055 · Zafar Siddique
Security guards failed to respond to an activated fire exit alarm at a location with a history of a near-fall incident, indicating …
|
1/5 |
| 21 Feb 2018 |
Richard Phillips-Schofield
2018-0054 · David Clark
There are no formal, effective national procedures for halting cycle races after an accident, leading to other riders passing through dangerous aftermaths.
|
1/6 |
| 21 Feb 2018 |
Alan MacDonald
2018-0053 · ME Hassell
A non-medically qualified counsellor charged an inpatient for non-treatment visits and failed to advise them on financial alternatives, revealing a systemic omission …
|
1/1 |
| 13 Feb 2018 |
Natasha Ford
2018-0052 · Zafar Siddique
A previous self-harm incident involving a plastic bag led to temporary restrictions, but these were later removed due to a policy change …
|
1/2 |