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.

Response tracker Organisations Advanced search

Keyword

Browse by year

Browse by region

Sort

Reports

6,384 reports · Page 219 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
1 Aug 2017	Hayley Sheehan 2017-0324 · Anna Crawford The repeat prescription procedure is unsafe as it relies on manual flagging of early requests, with software unable to automatically identify them. …	South East Surrey	Moat Surgery	1/1
27 Jul 2017	Maureen Colclough 2017-0318 · Jean Harkin Care home staff received inadequate training to recognise emergency situations and relied on presumptions when encountering an unresponsive patient.	North West Cheshire	Care Agency Care Quality Commission	2/2
2 Aug 2017	Thomas Wall 2017-0321 · Veronica Hamilton-Deeley The lack of local in-patient detox facilities and long waiting lists are unacceptable. A more collaborative approach for dual diagnosis patients is …	South East Brighton and Hove	BLANK_REDACTED_TEXT Pavilions Brighton and Hove Clinical Commissioning … Pavilions Pavilions (Surrey Borders Trust)	3/5
4 Aug 2017	Sharon Halliwell 2017-0319 · Jennifer Leeming The significant issue of "lack of connectivity" identified in evidence had not been fully addressed by the Trust.	North West Manchester (West)	North West Boroughs Healthcare NHS …	1/1
8 Aug 2017	Maya Kantengule 2017-0317 · Jacqueline Lake Significant safety risks arose from a lack of formal health and safety training, absence of specific risk assessments for swimming pool birthday …	East of England Norfolk	Waveney River Centre	1/1
9 Aug 2017	James Vinson 2017-0338 · Derek Winter The deceased was not under required close supervision despite a falls risk assessment, and plans for implementing an Enhanced Care/Observation Standard Operating …	North East Sunderland	City Hospitals Sunderland NHS Trust	1/1
9 Aug 2017	Sean Plumstead 2017-0316 · Grahame Short Winchester Prison has inadequate systems for storing electronic material and creating transcripts, leading to missing crucial evidence. This recurring issue raises a …	South East Hampshire (Central)	Carillion HM Prison and Probation Services HM Prison Winchester	3/3
19 Jul 2017	Ozeivo Akerele 2017-0337 · Sean McGovern Police failed to locate the deceased during an intensive search due to a critical oversight in searching a nearby disused graveyard, and …	West Midlands Coventry	West Midlands Police	1/1
21 Jul 2017	James Allbones 2017-0336 · Elizabeth Didcock A lack of consultant paediatrician review, inadequate sepsis training, poor handover protocols, and insufficient paediatric staffing levels put sick children at serious …	East Midlands Nottinghamshire	Bassetlaw Clinical Commissioning Group Care Quality Commission Doncaster and Bassetlaw Hospital NHS …	0/3
24 Jul 2017	Ben Jukes 2017-0335 · Nick Stanage The army's drug-testing regime failed to detect a serviceman's regular drug use, partly because tests were not random or unannounced, allowing evasion.	North West Manchester (City)	Ministry of Defence	1/1
21 Jul 2017	James Harris 2017-0334 · Emma Brown Care home staff failed to read care plans, adhere to falls protocols, and provide medical attention after a fall, compounded by poor …	West Midlands Birmingham and Solihull	Care First Class UK Limited Care Quality Commission	2/2
25 Jul 2017	Robert Dymond 2017-0333 · Emma Whitting Hospital DVT protocol did not align with NICE guidelines, and critical DVT history was not communicated to surgical teams, leading to a …	West Midlands Coventry	Coventry & Warwickshire NHS Trust	1/1
26 Jul 2017	Kenneth Swift 2017-0331 · John Broadbridge An elderly patient at high risk of falls was not provided with an essential falls sensor due to equipment shortages and a …	Yorkshire and the Humber York	York Teaching Hospital NHS Trust	1/1
27 Jul 2017	Percy Jacks 2017-0329 · Andrew Barkley Communication breakdowns between hospital, GP, and care homes, including incorrect information transfer and inadequate medication review systems, led to poor DVT management.	Wales South Wales Central	Care Quality Commission Care & Social Services Inspectorate … Local Health Board Welsh Government	4/4
27 Jul 2017	Sheila Gaskin 2017-0328 · Andrew Barkley Despite an identified risk of smoking in bed, carers regularly assisted the deceased to smoke, due to a lack of management oversight …	Wales South Wales Central	Care Quality Commission Welsh Government Office	2/2
28 Jul 2017	Pamela Keech 2017-0327 · Hassan Shah A critical lack of national guidance and A&E/paramedic training on predicting and managing fatal graft/fistula haemorrhage results in inadequate escalation of patients …	East Midlands Northamptonshire	British Renal Society Health Education England JRCALC Renal Association	2/5
13 Jul 2017	Edwin O’Donnell 2017-0258 · Andre Rebello Prison health reception screening failed due to lack of access to critical mental wellbeing documents and significant delays in follow-up screening. Additionally, …	North West Liverpool & Wirral	HM Prison and Probation Services	1/1
9 Aug 2017	Dennis Redmore 2017-0315 · Andrew Barkley Clear failures in neurological monitoring, with substantial observation gaps and delayed action on elevated vital signs, were identified. There was also a …	Wales South Wales Central	ABMU Health Board	1/1
31 Oct 2017	Gordon Penistan 2017-0313 · Grahame Short Other local authority Adult Services could benefit from lessons learned and actions taken in this case to address shortcomings, suggesting the need …	South East Hampshire (Central)	Adult Social Services	1/1
31 Oct 2017	Kate Pierce 2017-0312 · David Lewis There is a lack of clarity on when a sick child needs senior paediatrician review before discharge, especially with parental concerns. Additionally, …	Wales North Wales (East & Central)	Betsi Cadwaladr University Health Board	1/1