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 215 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
23 Nov 2017	Michaela Haines 2017-0415 · Jonathan Layton The police STORM report was not consistently updated, leading to uncertainty about completed actions, potential loss of evidence, and duplicated work, highlighting …	Wales Carmarthenshire & Pembrokeshire	Dyfed-Powys Police	1/1
20 Nov 2017	Peter King 2017-0414 · Patricia Harding Multiple deaths resulted from inadequate, incomplete, or unenforced falls risk assessments on the ward, including poor documentation, lack of intervention, and failure …	South East Kent (Central & South East)	East Kent Hospitals University NHS …	1/1
20 Nov 2017	Henry Honour 2017-0413 · Patricia Harding Multiple deaths on a ward were linked to inadequate or unenforced falls risk assessments. Specific to this case, the assessment was perfunctory, …	South East Kent (Central & South East)	East Kent Hospitals University NHS …	0/1
22 Nov 2017	Kathleen Devine 2017-0411 · Timothy Brennand A high-risk falls resident sustained injuries due to an unplugged falls mat, unrecorded observations, and inadequate handover information for agency staff regarding …	North West Manchester (West)	Arden Court Nursing Home Bloomcare	1/2
16 Nov 2017	Anthony Grant 2017-0410 · ME Hassell A lifeguard failed to notice a submerged swimmer for over five minutes due to inadequate pool safety protocols, including insufficient staffing and …	London London Inner (North)	Royal Life Saving Society UK	1/1
22 Nov 2017	Susan Smalley 2017-0409 · Katy Skerrett Concerns include insufficient ambulance resources, unclear guidance on hospital destinations for patients, and inadequate processes for expediting urgent inter-hospital transfers.	South West Gloucestershire	Gloucestershire NHS Trust South Western Ambulance Service NHS …	0/2
20 Nov 2017	Harold Wonfor 2017-0408 · Kate Thomas Multiple deaths occurred on a ward due to inadequate, incomplete, and unenforced falls risk assessments. Policies for vulnerable patients and the monitoring …	South East Kent (Central & South East)	East Kent Hospitals University NHS …	1/1
20 Nov 2017	Sarah Kiff 2017-0407 · Lisa Hashmi GPs failed to follow cancer referral guidance, exhibited poor communication and record-keeping, and provided perfunctory care. Additionally, processes for reviewing test results …	North West Manchester (North)	Stonefield Street Surgery	1/1
20 Nov 2017	Robert Richards 2017-0406 · Fiona Wilcox HMP Wandsworth suffered from pervasive bullying due to inadequate staff, poor communication, insufficient training, and inappropriate cell allocation. Critical issues also included …	London London Inner (West)	HMP Wandsworth St George’s Hospital	0/2
17 Nov 2017	Paul Mullen 2017-0403 · Alan Walsh The "red flag system" for reporting uncollected methadone prescriptions is ineffective; reports don't reach key workers directly, delaying intervention. Lack of shared …	North West Manchester (West)	Greater Manchester Mental Health NHS … Hindley Health Centre Pharmacy	1/2
17 Nov 2017	Peter Saint 2017-0404 · Sean Horstead A lead anaesthetist's misunderstanding of physiology led to misinterpretation of capnography during resuscitation, resulting in unrecognised oesophageal intubation, a known issue not …	East of England Cambridgeshire and Peterborough	NHS England North West Anglia NHS Trust Royal College of Anaesthetists Difficult Airway Society	3/4
16 Nov 2017	John Haines 2017-0402 · Lisa Hashmi Mental health inpatients and those supported by Home Treatment Teams lack timely access to qualified psychological therapy, a repeated concern due to …	North West Manchester (North)	Bury, Rochdale & Oldham Clinical … Department of Health and Social … NHS England Pennine Care NHS Trust	1/4
17 Nov 2017	Kathryn Richmond 2017-0401 · Rachael Griffin The ambulance service's non-staggered shifts meant multiple ambulances were unavailable for calls during simultaneous meal breaks, critically reducing resources and delaying emergency …	South West Dorset	Ambulance Association Department of Health and Social …	1/2
17 Nov 2017	Mildred Griffiths 2017-0400 · Louise Hunt The care home's pressure sore risk assessment tool (Braden Score) underestimates risk and creates confusion with a national standard, as it doesn't …	West Midlands Birmingham and Solihull	St Giles Nursing Home	1/1
16 Nov 2017	Doreen Wilkins 2017-0399 · Chris Morris Carer rotas lack travel time allowance, leading to late arrivals for time-critical care, shortened visits, and clients not receiving the full duration …	North West Manchester (South)	Comfort Call Limited	1/1
16 Nov 2017	Timothy Smedley 2017-0398 · Lisa Hashmi Fragmented care resulted from out-of-hours services lacking joint access to NHS records. Additionally, patients with alcohol addiction faced difficulties accessing timely mental …	North West Manchester (North)	Department of Health and Social …	1/1
14 Nov 2017	Kathleen Smith 2017-0397 · Chris Morris The care home failed to notify the family and corporate risk of a resident's injury, preventing proper investigation and learning. Incident reporting …	North West Manchester (South)	Borough Care	1/1
14 Nov 2017	Brian Stannard 2017-0394 · Jacqueline Lake Nursing home staff were inadequately equipped to manage a patient with complex mental and physical ill health, particularly regarding self-harm risks. Incomplete …	East of England Norfolk	Norfolk & Suffolk NHS Trust	1/1
10 Nov 2017	Graeme Flatman 2017-0393 · Karen Dilks The A593 lacked appropriate signage warning road users of severe gradients and visibility limitations. Concerns were also raised about the suitability of …	North East Newcastle Upon Tyne	Cumbria County Council	1/1
13 Nov 2017	Jeff Antwis 2017-0392 · John Ellery A young person with suicidal ideation faced critical delays in receiving an urgent mental health review, despite family concerns. The practitioner lacked …	West Midlands Shropshire, Telford & Wrekin	South Staffordshire and Shropshire NHS …	1/1