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 220 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
24 Oct 2017	David Jackson 2017-0308 · Karen Harrold Lack of intervention for an immobile patient who deteriorated over two weeks at home due to refusal of medical assistance, exposing risks …	South East West Sussex	Fitzalan Medical Group West Sussex Clinical Commissioning Group	1/2
31 Oct 2017	Douglas McTavish 2017-0311 · David Lewis Whirlpool's risk assessment processes may not fully appreciate the extent of fire risk with its appliances, and the company may be too …	Wales North Wales (East & Central)	Whirlpool (UK) Appliances	1/1
31 Oct 2017	Bernard Hender 2017-0311-wp25922 · David Lewis Whirlpool's risk assessments for appliance fires were inadequate, with a dismissive approach to field data like reported fires. This prevents timely learning …	Wales North Wales (East & Central)	Whirlpool (UK) Appliances	1/1
30 Oct 2017	Jane Powell 2017-0310 · Lisa Hashmi The ease with which large quantities of prescription-only medication can be obtained over the internet poses a significant risk of future deaths.	North West Manchester (North)	Department of Health and Social … Home Office	1/2
30 Oct 2017	Michael Giles 2017-0309 · Geraint Williams Inconsistent handover processes, lack of senior weekend patient reviews, absence of leadership during crises, and poor medical record-keeping created risks in patient …	West Midlands Worcestershire	Worcestershire Acute Hospital Trust	1/1
27 Oct 2017	Stephen Coulson 2017-0307 · Rashid Sohail Inadequate systems for controlled drug management and patient observation policies, coupled with a failure to learn from investigations, posed risks to patient …	North West Manchester (City)	Care Quality Commission Central Manchester University Hospitals NHS England	2/3
19 Oct 2017	Ronald Brewer 2017-0306 · Katy Skerrett Inadequate administration, documentation, and dispensation processes for medications, especially palliative ones, posed risks in the care home.	South West Gloucestershire	Barchester Homes	1/1
20 Oct 2017	Liam Oldsworth 2017-0301 · Paul Cooper The serious incident analysis report was significantly delayed in being received by the coroner's office, hindering timely review and learning.	East Midlands Lincolnshire	United Lincolnshire Hospital	0/1
12 Oct 2017	Ruth Thompson 2017-0297 · Timothy Brennand The deceased's repatriation from Italy involved insufficient information given for informed consent, an inadequate handover from a German clinician with limited English, …	North West Manchester (West)	Insure and Co	0/1
12 Oct 2017	Douglas Hodges 2017-0290 · Heidi Connor The absence of a system to communicate clinical urgency for prescriptions between prescribers and community pharmacies on the NHS Spine creates a …	East Midlands Nottinghamshire	Managing Director of Cegedim NHS Digital Wells Pharmacy	2/3
19 Oct 2017	June Evans 2017-0302 · Caroline Topping Agency staff unfamiliarity led to unreferred pressure sores, clinicians were unaware of patient deterioration, nutritional advice was ignored, and understaffing compromised care.	South East Surrey	St Peter’s Hospital	0/1
13 Oct 2017	Christina Fletcher 2017-0295 · Lisa Hashmi A lack of clear regulatory guidance on 'red flag' systems for pharmacies to identify patients with similar details and inconsistent chain of …	North West Manchester (North)	General Pharmaceutical Council	0/1
23 Oct 2017	Sian Witheridge 2017-0305 · ME Hassell Mental health records were unavailable or unread, risk assessments were inadequate and unenforceable, and there was a misunderstanding of suicide risk coupled …	London London Inner (North)	Camden & Islington NHS Trust One Housing Group	1/2
12 Oct 2017	Carol Buchanan 2017-0294 · Timothy Brennand Itraconazole was prescribed without consulting GP Summary Care, and the prescription was not timely recorded, leading to an unappreciated drug interaction with …	North West Manchester (West)	Royal Bolton Hospital	1/1
10 Oct 2017	Christopher Kiernan 2017-0304 · Mark Beresford Ineffective communication pathways for sharing information directly with the RDaSH Crisis Team created risks in patient care.	Yorkshire and the Humber South Yorkshire (East)	Yorkshire Ambulance Service	1/1
11 Oct 2017	Patrick Clifford 2017-0291 · Rachel Galloway Lack of clear patient supervision policy in toilets, difficulties transferring radiology images between hospitals, and refusal to perform requested X-rays caused treatment …	North West Blackburn, Hyndburn and Ribble Valley	East Lancashire Hospitals NHS Trust	0/1
6 Oct 2017	Levi Cronin 2017-0287 · Peter Dean Concerns arose over inadequate information sharing between healthcare and prison staff, particularly regarding historical risk data. Poor recording of observable changes on …	East of England Suffolk	HMP Highpoint HM Prison and Probation Service NHS England	0/3
11 Oct 2017	Mark Vagnoni 2017-0286 · Ian Pears Inadequate risk assessments and mental health input during "patrol state", unhelpful electronic record layouts, and missing transfer documentation for prisoners posed significant …	East of England Bedfordshire & Luton	HMP Bedford HM Prison and Probation Service	1/2
10 Oct 2017	Bernard Cosgrove 2017-0285 · Alan Wilson Hospital staff failed to recognise a patient's dislocated hip for 7 days, despite clinical record entries and physical handling. This highlights insufficient …	North West Blackpool and Fylde	Blackpool Teaching Hospitals NHS Trust	1/1
21 Sep 2017	Derek Dudley 2017-0284 · Anna Loxton A community alarm operator ended a call with an elderly man who had fallen before he could get up, without checking for …	South East Surrey	CSS Telecare Service Elmbridge and Ewell Borough Council Tandridge District Council	0/3