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.

Response tracker Organisations Advanced search

Keyword

Browse by year

Browse by region

Sort

Reports

6,386 reports · Page 212 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
21 Feb 2018	Molly Mills 2018-0051 · Heidi Connor A complex road junction suffers from poor visibility due to an incline and queuing right-turning vehicles. Unclear right-of-way indications, inadequate signage, and …	East Midlands Nottinghamshire	Nottingham County Council	1/1
10 Feb 2018	Margaret Clark 2018-0050 · Simon Jones A change to new TOE probe sheaths (Ecolab) was linked to multiple fatal oesophageal tears, and these potentially unsafe sheaths may still …	North West Lancashire & Blackburn with Darwen	Medicines and Healthcare products Regulatory …	1/1
15 Feb 2018	Bethany Shipsey 2018-0049 · Geraint Williams The highly toxic and antidote-less drug DNP is readily available online and popular as a 'diet drug.' There is a lack of …	West Midlands Worcestershire	Department for Health	1/1
15 Feb 2018	Charlie Craig 2018-0048 · Chris Morris British Cycling does not conduct health assessments or medical screening for young riders on its World Class Programme, missing opportunities to identify …	North West Manchester (South)	British Cycling	1/1
15 Feb 2018	Timothy Shaw 2018-0047 · Caroline Beasley-Murray Healthcare staff showed confusion regarding intelligence reports, communication between departments was poor, and systems for reducing illegal substances and managing referrals needed …	East of England Essex	Care UK Clinical Services Essex Partnership University NHS Foundation … Farleys Solicitors LLP HM Prison and Probation Service	1/5
14 Feb 2018	John Lambton 2018-0046 · Derek Winter Care home staff, without medical training, made assumptions about a resident's health after falls, disregarded an ambulance request, and communicated insufficiently with …	North East Sunderland	Dairy Lane Care Centre	0/1
14 Feb 2018	Elaine Bradbrook 2018-0044 · Heidi Connor Multiple failures in escalating care for a deteriorating patient, inadequate risk reduction during transfer, and lack of internal investigation or learning by …	East Midlands Nottinghamshire	United Lincolnshire Hospitals NHS Trust	1/1
13 Feb 2018	Angela Byrne 2018-0042 · Fiona Wilcox W-CDAS staff are not applying training, leading to inadequate risk assessment for vulnerable patients, and there are poor communications between inpatient and …	London London Inner (West)	Wandsworth Consortium Drug and Alcohol …	0/1
26 Jan 2018	Riaz Begum 2018-0041 · Anna Morris Significant delays in vital drainage and ERCP procedures occurred due to insufficient radiology staff, inadequate escalation, and a lack of cover during …	North West Manchester (South)	Tameside General Hospital NHS Trust	0/1
8 Feb 2018	Howard Winter 2018-0040 · Graeme Hughes An auxiliary nurse's recording of a patient's neck pain was not escalated to a doctor for further assessment, potentially delaying diagnosis of …	Wales South Wales Central	CWM Taff University Board	1/1
9 Feb 2018	Gail Bannister 2018-0039 · Andrew Cox The assigned Care Co-ordinator failed to see the patient, undermining their care plan. Additionally, a known single phone line problem severely hampered …	West Midlands Worcestershire	Worcester Health and care Trust	1/1
2 Feb 2018	Barbara Ellis 2018-0038 · Katy Skerrett A patient with cross-border care arrangements was unable to access therapeutic services because her healthcare was commissioned by one county and social …	South West Gloucestershire	Gloucestershire Clinical Group Herefordshire Clinical Commission Group	0/2
25 Jan 2018	Sandra Miller 2018-0037 · Peter Harrowing Urgent action is required to stop unsafe practices with open-ended urinary catheters, establish proper management procedures, and ensure all staff are adequately …	South West Avon	Milestones Trust	0/1
6 Feb 2018	Evelyn Fisher 2018-0036 · Deborah Archer The over-70 driving license renewal system relies on self-reporting and lacks mandatory objective testing, failing to prevent individuals with unrecognised cognitive impairment …	South West Plymouth, Torbay and South Devon	Transport for London	0/1
6 Feb 2018	Mavis Reeves 2018-0035 · Ian Pears The analogue Careline system caused significant delays for emergency services due to connection times, a single phone line, and key safe access …	East of England Bedfordshire and Luton	First Port Retirement Property Services …	1/1
25 Jan 2018	Sharon Grierson 2018-0034 · David Roberts There was a lack of appreciation for capnography readings, poor coordination, and senior staff lacked experience in crisis situations, highlighting a need …	North West Cumbria	Department for Health North Cumbria University Hospital NHS …	2/2
12 Apr 2018	James Sheffield 2018-0214 · Timothy Brennand Delays occurred in diagnosis and surgical intervention for a fracture, and a patient's essential CPAP machine went missing during hospital ward transfer.	North West Manchester (West)	Salford Royal NHS Trust	1/1
10 Apr 2018	Ellie Butler 2018-0421 · Dame Linda Dobbs No specific concerns were detailed in the provided text, only a reference to appended concerns.	London London (South)	Cafcass Department for Housing, Communities and … London Borough of Sutton Services for Children	0/7
10 Apr 2018	Andrew Reid Alison Mutch Inconsistent mental health service commissioning in Greater Manchester means Trafford residents lack out-of-hours emergency GP referrals, forcing A&E attendance or police involvement.	North West Manchester (West)	Trafford Clinical Commissioning Group Greater Manchester	2/2
29 Mar 2018	Margaret Spencer Zafar Siddique Inadequate staff training for a new IT system resulted in premature closure of patient access plans and lack of reviews, placing multiple …	West Midlands Black Country	Walsall Healthcare NHS Trust (Manor …	1/1