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 218 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
10 Nov 2017	Darren Powney 2017-0346 · Derek Winters Emergency ambulance staff showed confusion and lack of awareness regarding critical dynamic risk assessment protocols, including a 2016 policy. There was no …	North East Sunderland	North East Ambulance Service NHS …	1/1
20 Dec 2017	Scott Rayner 2017-0345 · Edward Solomons Inadequate fencing adjacent to the railway track, specifically behind a scrap metal dealer, presented a significant risk of trespass onto a high-speed …	East of England Hertfordshire	Network Rail	1/1
2 Nov 2017	John Nichols 2017-0344 · Johanna Thompson The fire drills policy lacked safeguards to adequately monitor residents, especially those with dementia, before, during, and after drills.	East of England Norfolk	Eastgate Residential Care Homes King's Lynn Residential Care Homes	1/2
31 Oct 2017	William Bergman 2017-0343 · ME Hassell A staff nurse prematurely dismissed a head injury as minor, failing to conduct vital observations or seek medical review for an elderly …	London London Inner (North)	Barts Hospital NHS Trust	0/1
26 Jan 2018	Andrew Finlay Derek Winter Persistent paramedic vacancies continue to cause concerns regarding the timely despatch and arrival of ambulances, posing a risk of future deaths due …	North East Sunderland	North East Ambulance Service NHS …	1/1
22 Jan 2018	Caliel Smith-Kwami Nadia Persaud Critical insulin and amino acid results were delayed due to lab analyser faults and unchased; the electronic record system failed to alert …	London London (East)	Barts Health NHS Trust	1/1
12 Jan 2018	Lee Daniel Caroline Sumeray Inadequate road markings, specifically the absence of double yellow lines, allowed legal parking to obstruct visibility, forcing drivers onto the wrong side …	South East Isle of Wight	Isle of Wight Council Highways …	1/1
28 Dec 2017	Mark Welsh 2017-0456 · ME Hassell Transport for London displayed an inordinate delay in implementing pedestrian crossings at a dangerous junction, using flawed decision-making based on incomplete accident …	London London Inner (North)	Transport for London	1/1
14 Dec 2017	Ernest Smith 2017-0459 · Anna Crawford The system for managing GP correspondence and medication review requests remains flawed. There is also no clear system to update GPs when …	South East Surrey	Surrey and Borders Partnership NHS …	1/1
22 Dec 2017	Ronald Farrington 2017-0494 · Caroline Topping The care centre failed to implement specialist nursing advice, kept inaccurate records, and didn't seek medical attention for infection, exacerbated by inadequate …	South East Surrey	Surrey First Community Health Care Care Quality Commission Saffronland Homes limited Surrey County Council	2/4
9 Nov 2017	Timothy Atkins 2017-0265 · David Horsley A narrow, pinch-point corner on a shared cycle/pedestrian pavement posed a safety risk due to poor visibility and the absence of a …	South East Portsmouth and South East Hampshire	Portsmouth City Council	1/1
6 Nov 2017	Harminder Dhillon 2017-0266 · Ian Pears The level crossing lacked CCTV monitoring and was prone to misuse due to insufficient half-barriers. The coroner suggested full-length barriers to prevent …	East of England Bedfordshire and Luton	Network Rail	1/1
16 Oct 2017	Jeremy Marshall 2017-0296 · David Ridley Unrealistic expectations of junior doctors, delays in escalating care for deteriorating patients, and unclear responsibility for ensuring timely senior clinician contact were …	South West Wiltshire & Swindon	Great Western Hospital NHS Trust	1/1
23 Jun 2017	Andrew Codling 2017-0339 · Ian Pears A community health team's voicemail to a patient missed an opportunity to reinforce crisis support numbers, potentially contributing to a missed chance …	East of England Bedfordshire and Luton	East London NHS Trust	1/1
19 Dec 2017	Naomi Sourbut John Tomalin Recommendations from a 2017 root cause analysis report regarding suicidal ideation and protective factors for individuals expressing intent to self-harm were not …	South West Exeter and Greater Devon	Devon Partnership Trust	0/1
8 Aug 2017	Fallon Abby 2017-0288 · ME Hassell Lack of a protocol for contacting social workers led to a failure in obtaining valuable collateral history and sharing crucial information, depriving …	London London Inner (North)	East London NHS Trust	1/1
24 Jul 2017	Richard Davies 2017-0325 · Nicholas Moss A police armed policing unit used unbonded ammunition which did not align with national recommendations and lacked a clear bullet mass retention …	East of England Cambridgeshire and Peterborough	Bedfordshire Police Constabulary Cambridgeshire police forces Hertfordshire police forces National Police Council	1/4
31 Jul 2017	Philip Clayton 2017-0323 · Alison Mutch High-powered kit cars are sold without requiring specific driving courses, and their post-initial testing lacks rigor. Inexperienced drivers can operate these vehicles …	North West Manchester (South)	Department for Transport	1/1
31 Jul 2017	Michael Bingham 2017-0322 · Anna Morris Harbour Healthcare failed to implement alarms for insecure internal doors, highlighting a risk assessment "blind spot." The CQC must review regulations and …	North West Manchester (South)	Care Quality Commission Harbour Healthcare Stockport NHS Trust	1/3
4 Aug 2017	Carly Gordon 2017-0320 · Geoffrey Tomalin The long-term use of shorter-acting benzodiazepines, contrary to guidelines, and a failure to review patients on extended prescriptions risked dependence and adverse …	South West Exeter & Greater Devon	Devon Local Medical Centre Devon NHS Trust Fremington Medical Centre NHS England	4/5