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 216 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
13 Nov 2017	John Scallan 2017-0391 · Bina Patel Patient observations were inconsistent and inadequate, failing to detect deterioration in a sedated patient. Staff lacked understanding of observation policy and were …	West Midlands Coventry	Coventry and Warwickshire NHS Trust	0/1
30 Oct 2017	Stuart Campbell 2017-0390 · Alison Mutch Inadequate guidance and clinical support for ADS workers, coupled with a failure to follow escalation protocols and properly document shared care discussions, …	North West Manchester (South)	ADS	1/1
12 Feb 2018	John Sloan Christopher Williams Mental health professionals failed to inquire about suicidal ideation and did not record concerns from the patient's daughter, representing missed opportunities to …	London London Inner (South)	Oxleas NHS Foundation Trust Department of Health The Chief Coroner	0/3
28 Dec 2017	Michael Drewry 2017-0386 · Andrew McNamara The Crisis Team failed to provide consistent care, maintain accurate records, or promptly escalate concerns, leading to delays in crucial decision-making regarding …	East Midlands Nottinghamshire	Nottinghamshire Healthcare NHS Trust	1/1
22 Dec 2017	Russell Robb 2017-0385 · Alison Mutch A lack of regular medication reviews and guidelines on drug quantities, coupled with limited information sharing between safeguarding bodies, meant significant police …	North West Manchester (South)	Trafford Adult Safeguarding Board Trafford Clinical Commissioning Group	1/2
21 Dec 2017	Sheila Ross 2017-0384 · Veronica Hamilton-Deeley The report is incomplete and does not contain any specific concerns from the coroner.	South East Brighton and Hove	Carlton House Rest Home Compliance Manager	0/2
18 Dec 2017	Anne Morris 2017-0383 · Christopher Williams Hospital staff did not contact friends and relatives after the patient consented, and there was no written plan identifying the responsible team …	London London Inner (South)	Oxleas NHS Trust Department of Health The Care Quality Commission The Chief Coroner	2/5
21 Dec 2017	Margaret Postill 2017-0382 · Alison Mutch There was a lack of patient evaluation and incomplete assessment sheets after the deceased's return to the care home, compounded by poor …	North West Manchester (South)	Sunnyside Care Centre Tameside General Hospital	1/2
18 Dec 2017	Stephen Shaylor 2017-0380 · Elizabeth Earland Prison healthcare for detox inmates was "not fit for purpose" due to insufficient stabilisation places and inadequate night welfare checks. Intermittent observations …	South West Exeter and Greater Devon	Care UK Dorset Health Care University Home Office	1/3
20 Dec 2017	Craig Royce 2017-0379 · Caroline Beasley-Murray A lack of a formal, robust documentary system for referring prisoners to mental health services meant reliance on unreliable telephone conversations, risking …	East of England Essex	Bindmans Solicitors Care UK Essex Partnership NHS Trust HM Prisons and Probation Service	1/5
19 Dec 2017	Lindsey Parker 2017-0378 · Lisa Hashmi Multiple issues included a lack of continuity in medical care, significant gaps in basic nursing observations, failure to recognise patient deterioration, and …	North West Manchester (North)	Salford Royal Hospital	1/1
28 Nov 2017	Harold Chapman 2017-0377 · Julian Morris Patient emails to consultants were frequently unread and unanswered, indicating a need for clear national or local guidelines on patient-clinician communication methods.	London London Inner (South)	Barts Health NHS Trust Brompton NHS Trust Secretary of State for Health	3/3
6 Nov 2017	Ryan Vout 2017-0376 · Andrew McNamara There was a lack of coordinated psychiatric discharge, failing to involve professionals and family. Also, ambulances could not be pre-arranged for Mental …	East Midlands Nottinghamshire	NHS England Department for Health Nottingham County Council Nottingham Police	3/8
18 Dec 2017	Mark Doyle 2017-0375 · Heather Williams Significant failings in ACCT case reviews, inadequate healthcare information sharing, and a lack of clear criteria for prisoner transfer decisions were identified. …	London London Inner (North)	Care UK HMP Pentonville HM Prisons and Probation Service	1/3
18 Dec 2017	Pamela Hands 2017-0373 · Emma Carlyon A critical risk of respiratory depression in opioid-treated patients receiving nerve blocks was not widely recognised, and national monitoring guidelines were absent. …	South West Cornwall and the Isles of Scilly	Royal College of Emergency Medicine Royal College of Surgeons	1/2
13 Dec 2017	Maurice Wrightson 2017-0372 · Tony Brown Volvo vehicle manuals provide insufficient guidance on using automatic i-shift gears for long downhill descents, which could exacerbate brake fade. Manufacturers need …	North East Northumberland (North)	Volvo Group (UK) Limited	1/1
12 Dec 2017	Joseph Dune 2017-0371 · Caroline Sumeray Significant breaches in Information Governance allow clinicians to alter patient records under incorrect logins, making these critical changes invisible to treating clinicians …	South East Isle of Wight	Care Quality Commission Isle of Wight NHS Trust St Mary’s Hospital	0/3
18 Dec 2017	Daniel Watson 2017-0370 · John Gittins A root cause analysis identified numerous care and service delivery problems, missed opportunities, and a lack of staff understanding. Significant improvements are …	Wales North Wales (East and Central)	Betsi Cadwaladr University Health Board Wrexham County Council Ysbyty Gwynedd	2/3
13 Dec 2017	Rebecca Romero 2017-0369 · Maria Voisin The patient was discharged into an inadequate community care package with insufficient post-discharge contact and delayed medical review. There was confusion over …	South West Avon	Avon & Wiltshire Mental Health … Dorset Healthcare University NHS Trust NHS England	0/3
12 Dec 2017	Francis Beech 2017-0367 · Louise Hunt The hospital lacked clear guidelines for high-risk fracture management, leading to poor continuity of care and inadequate discharge planning. The nursing home …	West Midlands Birmingham and Solihull	Heart of England NHS Trust St Giles Care Home	1/2