Ross Reeves
AI-generated concerns summaryThe coroner raised concerns that the patient's transfer to their new GP was likely unsafe.
Addressed to: Brighton and Hove Clinical Commission Group; British Medical Association; NHS England
Source · Prevention of Future Deaths
Prevention of Future Deaths Reports
Browse 6,471 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
Matthew Gayle
AI-generated concerns summaryThe coroner identified concerns regarding the declining number of consultant histopathologists available to perform autopsies for coroners, noting that the absence of histology in Matthew's case might have impacted determining an accurate cause of death.
Addressed to: Department of Health and Social Care
Joan Osborne
AI-generated concerns summaryConcerns included the nursing home's failure to seek specialist diabetes and dementia outreach assistance, adequately manage Mrs Osborne's insulin refusal, or recognise her deteriorating condition. Inadequate record keeping and incorrect medication administration were also noted.
Addressed to: Adbolton Hall Nursing Home
Maureen Campbell-Scott
AI-generated concerns summaryThe coroner identified significant delays in mental health referrals due to misdirection and loss, and frequent delays in delivering clinic letters from the mental health trust to the GP. This caused challenges for GPs in rapidly and accurately implementing specialist-directed medication changes, indicating a need for improved inter-agency communication and …
Addressed to: North East London Trust; Fullwell Cross Medical Centre
John Wherlock
AI-generated concerns summaryThe coroner noted insufficient ward cover due to staff taking breaks simultaneously, leaving the deceased unsupervised before a fall. The report also highlights that this practice continued despite being identified in a serious incident report.
Addressed to: Bristol NHS Trust
Anthony Paine
AI-generated concerns summaryThe coroner noted the circumstances where an individual on hourly mental health checks was found deceased shortly after a check, having used a bedsheet and a light fitting as a ligature point.
Addressed to: HM Prison and Probation Service; Ministry of Justice; The Chief Coroner of England and Wales
Edward Lundy
AI-generated concerns summaryThe coroner identified a lack of continuity in care and inadequate independent family consultation regarding risks upon discharge. Additionally, there was insufficient clarity in the referral for psychiatric review and no evidence that the Trust's recommended actions were implemented or shared nationally.
Addressed to: South London and Maudsley NHS Trust
Leigh Wilde
AI-generated concerns summaryThe coroner noted a lack of supporting documentation and consideration of risk factors when suspending an employee, with no evidence of referral to support services. Additionally, the approach to whistleblowers and their support was unclear.
Addressed to: IMI (Institute of the Motor Industry); LTE Group
David Sketchley
AI-generated concerns summaryThe report identifies concerns regarding the quality of the BUPA investigation, which did not conclude on supervision levels or commode suitability. It also notes an absence of evidence that BUPA's practice reflects care service standards for commode assessments.
Addressed to: BUPA UK; CARE QUALITY COMMISSION; Medicines and Healthcare Products Regulations Authority; Performance Health
Venkata Kagga
AI-generated concerns summaryThe coroner noted insufficient safety features for button batteries in household devices and a lack of understanding of their risks. Concerns were also raised about non-compliance with policies for young children in emergency services, inadequate medical assessments, and poor information sharing across NHS services.
Addressed to: The Royal Society for Prevention of Accidents; Healthcare Safety Investigation Branch; Department of Health and Social Care; NHS England; Secretary of State for business
Ellie Clark
AI-generated concerns summaryThe coroner identified a lack of robust care planning and single clinician oversight. Concerns were also raised about the emergency appointment triage system, including a patient being turned away without clinical assessment and critical medical notes not being prominently displayed or shared.
Addressed to: Aneurin Bevan University Health Board; Grange Clinic
Rastislav Petrisko
AI-generated concerns summaryThe coroner identified inconsistencies in risk assessment and its application to granting leave, noting a significant delay in police notification for an absconded patient due to a 'period of grace' in the existing policy.
Addressed to: Oxleas Mental Health Trust
Kenneth Longley
AI-generated concerns summaryThe coroner noted a nearly three-month delay in sending a doctor's letter to the patient's GP about severe aortic stenosis, due to challenges in obtaining medical records and administrative processing. This raises concerns about future deaths if similar communication delays occur.
Addressed to: Graham Street, Beswick, Manchester; Wythenshawe Hospital
Barbara Johnson
AI-generated concerns summaryThe coroner noted that junior doctors at Pennine Acute NHS Trust were routinely ignoring automated ECG printout summaries, which meant these printouts were not informing clinical interpretation and judgment.
Addressed to: Pennine Acute NHS Trust
Kellie Taylor
AI-generated concerns summaryThe coroner identified that the poor resolution and quality of the CCTV system on the bridge prevented accurate monitoring of individuals' behaviour, potentially hindering timely intervention in emergencies.
Addressed to: Humber Bridge Board
Janet Hall
AI-generated concerns summaryConcerns were raised about the Emergency Department's system for discharge letters, which relies on junior doctors manually transcribing blood results, leading to an incorrect statement about normal bloods. This process also limits GPs' ability to perform trend analysis.
Addressed to: Pennine Acute Hospitals NHS Trust
Sheila Ross
AI-generated concerns summaryThe falls risk assessment tool was outdated, and recorded risk levels did not match the assessment score. The buzzer system's limitations could delay assistance, and poor communication with the family reduced their confidence in care.
Addressed to: Hylton View Care Home
Jean Griffiths
AI-generated concerns summaryThe coroner noted concerns regarding poor prescribing practices for oxygen, with a significant percentage of patients receiving supplementary oxygen without a valid prescription. This poses a risk that patients may receive inappropriate oxygen levels, potentially increasing mortality.
Addressed to: Department of Health and Social Care
Georgia Polydorou
AI-generated concerns summaryThe coroner noted a delay in performing a CT scan within 8 hours for an elderly patient on multiple blood thinners after a fall, with expert evidence suggesting delayed symptom onset. Additionally, communication with the patient's son about deterioration signs was insufficient given language barriers.
Addressed to: Homerton Healthcare NHS Foundation Trust; N.I.C.E
Freddie Dobinson-Evans
AI-generated concerns summaryThe coroner noted that genetic test results indicating a pathogenic gene mutation were misinterpreted, leading to a family being incorrectly informed the results were "absolutely normal." This situation carries a risk of similar miscommunications impacting other children.
Addressed to: Great Ormond Street Hospital for Children NHS Foundation Trust; Barts Health NHS Trust