Source · Prevention of Future Deaths

Prevention of Future Deaths Reports

Browse 6,384 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

6,384 reports · Page 213 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
1 Feb 2018	David Green 2018-0027 · Caroline Beasley-Murray The worksite lacked a safe system of work, and there was a widespread practice of employees not wearing seatbelts, with inadequate systems …	East of England Essex	Rose Builders and Contractors Ltd	0/1
26 Jan 2018	Joan Betteridge 2018-0026 · Karen Harold Inadequate systems for requesting and tracking X-rays in GP surgeries and hospital ED led to significant delays in repeat X-rays and radiology …	South East Hampshire (Central)	Hampshire NHS Trust Park & Francis Surgery	2/2
24 Jan 2018	Reginald Key 2018-0025 · Margaret Jones A post-operative patient's condition significantly deteriorated during a prolonged 4-hour patient transport journey home after hospital discharge, raising concerns about monitoring during …	West Midlands Stoke-on-Trent and North Staffordshire	Staffordshire Clinical Commissioning Group	1/1
19 Jan 2018	William Lound 2018-0022 · Kevin McLoughlin Care for the attacker was fragmented, lacked continuity, and failed to recognise warning signs of violence due to insufficient clinical conferencing and …	North West Manchester (West)	Greater Manchester Mental Health NHS …	1/1
18 Jan 2018	Paul Hanton 2018-0021 · Penelope Schofield Concerns involve inadequate information sharing during 999 calls for AWOL patients, limited hospital CCTV access for police, and a discernible difference in …	South East West Sussex	Sussex Partnership NHS Trust Sussex Police	2/2
18 Jan 2018	Abdul-Jamal Ottun 2018-0020 · Andrew Harris Critically inadequate risk assessment, supervision, and swimming education for school open-water activities failed to prepare students for cold natural waters, highlighting a …	London London Inner (South)	Department for Education	1/1
17 Jan 2018	Barry Tucker 2018-0018 · Veronica Hamilton-Deeley No specific concerns were detailed in the provided text.	South East Brighton & Hove	Brighton and Sussex University Hospitals NHS England CCG, Eastbourne East Sussex Health Care NHS …	1/5
16 Jan 2018	Keith Harwood 2018-0017 · Alan Wilson Medical professionals struggle to access urgent specialist advice for unfamiliar conditions despite Trust policies, potentially delaying appropriate care and requiring families to …	North West Blackpool & the Fylde	Blackpool Teaching Hospitals NHS Trust	1/1
16 Jan 2018	Edwin Hooper 2018-0016 · Christopher Murray Concerns exist regarding ensuring timely CT scanning for head injury patients on anti-coagulants, in line with NICE guidelines, especially when facing service …	North West Manchester (South)	Manchester University NHS Trust	1/1
10 Jan 2018	John Edwards 2018-0015 · Margaret Jones The care home was unable to manage complex needs, demonstrating inadequate policies for falls and pressure sores, poor record-keeping, and a failure …	West Midlands Staffordshire (South)	Community Disability Nurse Independent Futures, Southwinds Care Home	1/2
15 Jan 2018	Antony Coughtrey 2018-0014 · Thomas Osborne The Probation Service failed to conduct an internal investigation or Serious Incident Review after a prisoner's death on licence and had a …	South East Milton Keynes	HM Inspectorate of Probation	0/1
11 Jan 2018	Donald Till 2018-0013 · Margaret Jones Unavailable medical records, inadequate equipment (missing bronchoscope part, no tilt trolley), and unutilised standard procedures (cricoid pressure, NG tubes) compromised patient care …	West Midlands Stoke-on-Trent & North Staffordshire	University Hospitals of North Midlands	1/1
10 Jan 2018	John O’Meara 2018-0012 · Sarah Ormond-Walshe Prison officers inconsistently followed Code Blue/Red procedures, delaying emergency response and Naloxone administration due to inadequate training. There's also an insufficient number …	London London (West)	HMP Wormwood Scrubs	1/1
12 Jan 2018	Christopher Hutton 2018-0011 · Alison Mutch Significant backlogs and high demand within Probation services meant a critical court-ordered treatment program for the deceased was not commenced, despite his …	North West Manchester (South)	National Probation Service	1/1
12 Jan 2018	David Buttriss 2018-0010 · Emma Carlyon Critical communication breakdowns between GP and mental health services, fragmented healthcare records, and a lack of clarity in mental health crisis pathways …	South West Cornwall and the Isles of Scilly	Cornwall Health Cornwall NHS Trust NHS England	3/3
12 Jan 2018	Pauline Pryor 2018-0009 · Emma Carlyon Critical communication failures between the nursing home and GP, an inadequate system for monitoring lithium toxicity, and an unread consultant email led …	South West Cornwall and the Isles of Scilly	NHS England	1/1
12 Jan 2018	John Armstrong 2018-0008 · D Hocking A lack of mandatory, compatible anti-collision systems and the absence of Air Traffic Control at a busy airfield created significant collision risks, …	East Midlands Leicester (City & South)	Civil Aviation Authority	1/1
11 Jan 2018	John Chapman 2018-0007 · Nicholas Rheinberg A critical lack of formal procedures for sharing prisoner self-harm and welfare alerts between prison reception staff and healthcare nurses during medical …	North West Lancashire	HMP Wymott	2/1
5 Jan 2018	Patrick Moran 2018-0006 · Jacqueline Devonish An insulin overdose occurred due to the common practice of using incorrect syringes, exacerbated by the removal of diabetes from mandatory training …	London London Inner (North)	Royal Free Hospital	0/1
5 Jan 2018	Marcus Hamilton 2018-0005 · Andrew Bridgman The mental health service's rigid 28-day prescription policy for maintenance medication left a patient vulnerable during extended travel, providing unreliable advice about …	North West Manchester (South)	Greater Manchester Mental Health NHS …	0/1