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.
Reports
| Date | Report | Responses identified |
|---|---|---|
| 12 Dec 2017 |
Sidonio Teixeira
2017-0366 · Geraint Williams
The adequacy of prison intelligence processes, including reporting and analysis, was questioned. A critical internal report on these issues was not shared …
|
0/1 |
| 8 Dec 2017 |
Roger Saxby
2017-0365 · Veronica Hamilton-Deeley
The provided text only states the coroner's statutory duty to report concerns without detailing specific issues identified.
|
1/2 |
| 11 Dec 2017 |
Irene Baker
2017-0363 · S Fox
The care home failed to revise mobility care plans despite documented deterioration and missed monthly reviews. They also failed to escalate concerns, …
|
1/1 |
| 8 Dec 2017 |
Benjamin Goodrum
2017-0362 · Jacqueline Lake
Although there was evidence of good communication with Mr Goodrum, the coroner noted that no one person took overall responsibility for him …
|
1/1 |
| 16 Nov 2017 |
Stephanie Cave
2017-0361 · Philip Spinney
Inconsistent application and recording of enhanced observations for at-risk mental health patients, coupled with a lack of training and written guidelines, compromised …
|
2/2 |
| 7 Dec 2017 |
Kenneth Cottam
2017-0360 · Anna Crawford
The court was not reassured that there are clear and robust policies and procedures in place in relation to falls prevention and …
|
1/1 |
| 4 Dec 2017 |
Gordon Thornhill
2017-0359 · Nicola Mundy
Incomplete VTE risk assessments by junior doctors, a consultant's failure to identify this and document their own assessment, and a significant delay …
|
1/1 |
| 8 Dec 2017 |
Stuart Walls
2017-0358 · Michael Mellun
The patient died from a synergistic toxic effect of multiple prescribed drugs, each within therapeutic range, affecting the central nervous system and …
|
0/2 |
| 14 Nov 2017 |
Steven Jones
2017-0357 · Raymond Curtis
Carers' concerns were not escalated or recorded, and staff failed to appreciate the importance of incident reports for illness. Delays in calling …
|
1/1 |
| 7 Dec 2017 |
Violet Nelson
2017-0356 · Peter Bedford
Lack of consultant oversight for ultrasound reports and GPs' unawareness that supra-renal aortic aneurysms indicate larger thoracic aneurysms led to delayed diagnosis. …
|
3/3 |
| 28 Nov 2017 |
John Lea
2017-0355 · Lisa Hashmi
Incomplete risk assessments, poor nursing communication, significant documentation gaps, and a failure to escalate concerns about a non-attending doctor led to incorrect …
|
0/1 |
| 15 Sep 2017 |
Marko Petrovic
2017-0354 · Martin Fleming
There are no written guidelines for dismantling cantilevered scaffolds, nor are specific Risk Assessment Method Statements (RAMS) required for this process, risking …
|
0/1 |
| 5 Dec 2017 |
Gwendoline Halfpenny
2017-0353 · Andrew Haigh
County Hospital lacked surgical cover, and there was inconsistency in MEWS systems, duty policies, and equipment between hospitals within the same Trust.
|
1/1 |
| 30 Nov 2017 |
Philip Powell
2017-0352 · Zafar Siddique
Delays in ordering wound care supplies were caused by poor communication and inadequate systems regarding the ordering process and overall responsibility.
|
1/1 |
| 5 Dec 2017 |
Joshua Hamill
2017-0351 · John Gittins
Police training was ineffective in identifying mental health issues, and 'concern for safety' incidents were closed without ensuring the individual's welfare.
|
1/1 |
| 30 Nov 2017 |
Sarah Athersmith
2017-0350 · Zafar Siddique
An unprotected level crossing lacked warning systems, causing confusion when multiple trains passed, and double-height freight carriages obscured views, increasing pedestrian danger.
|
2/4 |
| 30 Nov 2017 |
Penelope Benton
2017-0349 · Zafar Siddique
The General Practitioner was not informed of a previous tramadol overdose in the hospital discharge letter, preventing complete medical history.
|
1/1 |
| 4 Dec 2017 |
Dorothy Breislin
2017-0348 · Paul Cooper
There was a significant delay in submitting an incident review report, families did not receive an apology, and none of the recommended …
|
1/1 |
| 20 Sep 2017 |
Peter Cotter
2017-0388 · Thomas Osborne
Emergency service triage software failed to register a head injury in an anticoagulant patient after a fall, risking severe complications and highlighting …
|
2/1 |
| 4 Sep 2017 |
Liam Thomas
2017-0347 · Darren Salter
The patient had access to restricted plastic bags, possibly due to inadequate environmental safety checks on the ward. Additionally, communication with the …
|
1/1 |