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.

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6,384 reports · Page 214 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
4 Jan 2018	Dylan Hill 2018-0004 · Tanyka Rawden A critical lack of communication procedures meant a previous non-fatal anaphylactic reaction at a food business was not reported to Trading Standards, …	Yorkshire and the Humber South Yorkshire (West)	Department for Health Food Standards Agency	3/2
2 Jan 2018	Paul Daniels 2018-0003 · Alison Mutch An inadequate staffing ratio meant tree surgeons lacked qualified aerial support, and poor communication methods via shouting and hand signals hindered safety …	North West Manchester (South)	Arboricultural Association Forestry Commission Health and Safety Executive	3/3
3 Jan 2018	Margaret Silver 2018-0002 · Anna Crawford Contradictory information in discharge summaries led to the discontinuation of life-saving medication, which clinicians failed to identify despite patient contact. Additionally, occupational …	South East Surrey	Ashford and St Peter’s Hospital …	1/1
2 Jan 2018	Kristina Cross 2018-0001 · James Newman Delayed surgical fixation of a traumatically fractured femur, caused by initial and subsequent misdiagnoses, led to post-operative complications and significantly contributed to …	North West Lancashire & Blackburn with Darwen	Department for Health Ministerial Correspondence and Public Enquiries …	0/2
30 Nov 2017	Lindsey Hassall 2017-0429 · Alison Mutch There was no record of police information to mental health practitioners, delayed and destroyed patient notes, inaccessible documentation, and a GP's incorrect …	North West Manchester (South)	Change Glow Live Heaton Norris Health Centre Pennine Care NHS Trust	1/3
28 Nov 2017	Sonia Stante 2017-0428 · Jacqueline Devonish Confusing road layouts with absent pedestrian direction markings, independent green man phasing, and overly visible signals created hazards for pedestrians, especially foreign …	London London Inner (North)	Transport for London	1/1
29 Nov 2017	Christopher Talbot 2017-0427 · Nicholas Rheinberg An untrained supervising officer relied solely on shadowing, a senior officer lacked a breathing guard for resuscitation, and staff were not informed …	North West Preston and West Lancashire	HMP Preston HM Probation and Prison Service Ministry of Justice	0/3
28 Nov 2017	Edna Collett 2017-0426 · Andrew Haigh A patient remained in hospital unnecessarily for over two months due to the inability to secure a suitable social care placement, impacting …	West Midlands Staffordshire (South)	North Midlands NHS Trust	0/1
27 Nov 2017	Bernard Ovu 2017-0425 · Nadia Persaud Lack of clear written procedures for lone staff dealing with trespassers, inconsistent practice, and difficult access to CCTV for verification contributed to …	London London (East)	London Underground	0/1
27 Nov 2017	Shaun Berryman 2017-0424 · Simon Fox A patient's clinical assessment was conducted in a waiting area without a physical examination, and no clinical record was made of the …	South West Avon	Wells Road Surgery	1/1
27 Nov 2017	Jason Basalat 2017-0423 · Thomas Osborne Poor information sharing between police, magistrates' court, and prison meant the prison lacked critical details about a vulnerable prisoner's mental state, and …	South East Milton Keynes	HM Courts and Tribunals Service Northamptonshire Police	2/2
27 Nov 2017	Ayse Yalcinkaya 2017-0422 · Thomas Osborne Unclear signage at a motorway junction caused driver confusion about lane usage, and the absence of a run-off lane contributed to queuing …	South East Milton Keynes	Highways England	1/1
14 Nov 2017	Rose Ball 2017-0395 · Heidi Connor A doctor engaged in a pattern of telephone diagnoses, failed to accurately record consultations, and falsely documented examinations. Concerns extend beyond poor …	East Midlands Nottinghamshire	GMC Fitness to Practise Team	0/1
27 Nov 2017	Rafe Angelo 2017-0421 · Karen Harold Antenatal checks were insufficient for detecting growth restriction, lacked clear guidance for post-bradycardic episodes, and birthing centers lacked CTG. Transfer policies were …	South East Portsmouth & South East Hampshire	Department for Health Portsmouth Hospitals NHS Trust South Central Ambulance Service NHS …	2/3
27 Nov 2017	Barbara Howard 2017-0420 · Joanne Andrews Severe staff shortages across paramedic and emergency operations centres resulted in delayed responses, failure to prioritize calls, and an inability to meet …	South East West Sussex	South East Ambulance Service	1/1
20 Nov 2017	Terence Davies 2017-0419 · Terence Moore A dangerous "informal" pathway, used by pedestrians and cyclists, remains extant and poses a significant safety risk.	South West Avon	Banes Highways Banes Park and Services Canal Trust Bath	0/3
23 Nov 2017	Jonathan Shaw 2017-0418 · Maria Voisin Despite multiple prior incidents and an identified need for speed reduction, planned road signs and markings to improve highway safety at a …	South West Avon	Highways Department, Bat and North …	0/1
22 Nov 2017	Ann Maguire 2017-0417 · Kevin McLoughlin There is inconsistent management of weapon risks in schools; OFSTED should make it mandatory for inspectors to review and report on how …	Yorkshire and the Humber West Yorkshire (East)	Office for Standards in Education, …	1/1
23 Nov 2017	Ronald Jones 2017-0416 · David Horsley Lack of first aid training for staff moving residents after falls poses a risk of exacerbating injuries, as the city council discontinued …	South East Portsmouth and South East Hampshire	Portsmouth City Council	1/1
22 Nov 2017	Tomas Kelly 2017-0412 · Heidi Connor Parents of a child with Down Syndrome were not adequately informed of their child's increased infection risks, and routine chickenpox vaccination for …	East Midlands Nottinghamshire	Chief Medical Officer Committee on Vaccination and Immunisation National Clinical Director for Children … Public Health England	1/4