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 221 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
5 Oct 2017	Christopher Roberts 2017-0283 · Aled Gruffydd Care plan reviews lacked documentation, making it impossible to confirm outcomes or whether previous suicide attempts were considered. Additionally, Nomad trays might …	Wales Swansea, Neath and Port Talbot	ABMU Health Board	0/1
4 Oct 2017	Sofia Legg 2017-0293 · Tony Williams Concerns include a high CAMHS referral threshold, a six-month wait for CBT, and the care co-ordinator's failure to ensure urgent psychiatric input. …	South West Somerset	CAMHS NHS Somerset Clinical Commissioning Group Somerset County Council	4/3
6 Oct 2017	Geoffrey Spencer 2017-0281 · Chris Morris A serious patient injury lacked a formal investigation, limiting learning opportunities to improve resident safety, despite policy improvements.	North West Manchester (South)	Lakes Care Centre	1/1
5 Oct 2017	Simon Willans 2017-0280 · Nicola Jones The ambulatory care unit lacked effective scrutiny and the consultant failed to document patient care. Discharge by an uninvolved nurse practitioner, insufficient …	Wales North West Wales	Betsi Cadwaladr University Health Board	0/1
28 Sep 2017	Pauline Hayston 2017-0278 · Timothy Brennand Concerns focus on the unreliability of Rambleguard falls mats, which failed to activate or had significant delays in alarming staff. The suitability …	North West Manchester (West)	Department of Health and Social … Rambleguard Ltd Royal Bolton Hospital	1/3
19 Oct 2017	Jakub Moczyk 2017-0300 · Jacqueline Lake Inadequate pre-fight medical checks for boxers and medics failing to assess a boxer's fitness to continue after vomiting, relying instead on a …	East of England Norfolk	Lifeshield Medical Services Limited	1/1
18 Oct 2017	Wycliffe Matthews 2017-0299 · John Pollard Care home staff lacked adequate training on hoist use and failed to maintain proper records of critical events.	North West Manchester (West)	Grange Care Home	0/1
12 Oct 2017	Lesley Hanson 2017-0303 · Philip Spinney Inadequate care and risk assessments failed to address environmental safety hazards like open doors and stair-gate suitability, with unclear responsibility for control …	Wales South Wales Central	Cardiff City Council Medical Officer Welsh Government	2/2
12 Oct 2017	Jeremiah Obaka 2017-0292 · Selena Lynch Lack of a consistent, agreed policy between the local authority and care agency regarding actions when service users do not respond or …	London London (South)	London Borough of Sutton	0/1
7 Oct 2017	Marcin Mazurek 2017-0282 · Nicholas Rheinberg Medical record keeping was of very poor quality, and daily or tri-weekly medical checks in segregation were often not recorded or did …	North West Preston and West Lancashire	NHS England	0/1
27 Sep 2017	Pamela Craigie 2017-0279 · Gemma Brannigan The care home lacks clear criteria and staff confidence for requesting urgent 1:1 care funding from the local authority. Delays in urgent …	London London (West)	Advinia Healthcare Ltd London Borough of Hounslow	1/2
16 Aug 2017	Christopher Fairhurst 2017-0277 · Lisa Hashmi Systemic GP shortages, reliance on locums, and insufficient training are causing reduced patient access, poor continuity of care, and insufficient consultation times. …	North West Manchester (North)	Department of Health and Social …	0/1
16 Aug 2017	Spencer Hurst 2017-0275 · Zafar Siddique The coroner notes that another young male had died in similar circumstances at the same location in 2007, but there were no …	West Midlands Black Country	Parkhill Group of Companies Walsall Metropolitan Borough	1/2
15 Aug 2017	Ian Leak 2017-0274 · Alison Mutch The communal fire alarm system at Honiton Oaks failed to trigger audible alerts within individual flats, raising serious safety concerns for residents, …	North West Manchester (South)	Peak Valley Housing Association Hub	1/2
16 Aug 2017	Dorothy Webb 2017-0273 · Zafar Siddique A radiologist failed to assess a "mass" on a scan and note a fracture on an x-ray, missing critical opportunities for further …	West Midlands Black Country	Walsall Manor Hospital Trust	1/1
16 Aug 2017	Frederick Dudley 2017-0272 · Margaret Jones A dangerous, uncontrolled pedestrian crossing on a busy dual carriageway is obscured by a wall, located on a bend, and near a …	West Midlands Staffordshire (South)	Highways England	0/1
14 Aug 2017	Mark Banks 2017-0271 · Elizabeth Earland Police failures in call handling included not contacting ambulance services as requested, incorrectly grading a high-risk call, and insufficient efforts to search …	South West Exeter and Great Devon District	Devon and Cornwall Police Headquarters	1/1
10 Aug 2017	Claire Medhurst 2017-0270 · Patricia Harding The discharge process lacked crucial cautionary advice on medication use, and treating clinicians failed to receive alerts for abnormal liver function and …	South East Mid Kent and Medway	Medway NHS Foundation Trust	1/1
24 Nov 2017	Owen Widlake Sarah Whitby Inadequate staffing and training for NICU staff, particularly in escalating concerns and recognizing respiratory distress, compounded by unclear roles, poor observation recording, …	South East Southampton and New Forest	Isle Of Wight NHS Trust	0/1
9 Nov 2017	Daisy French 2017-0264 · Louise Slater The report identifies concerns regarding communication and information sharing between CAMHS and Adult Services, the transition of care, and out-of-hours provision for …	Yorkshire and the Humber South Yorkshire (West)	Department of Health and Social …	2/1