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 222 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
29 Sep 2017	Helen Bannister 2017-0255 · Crispin Butler Inaccurate and incomplete records regarding all aspects of care, including fluid intake, diet, and discharge instructions, compromised staff's ability to react properly …	South East Buckinghamshire	Fremantle Trust	0/1
9 Mar 2017	Peter Norton 2017-0251 · Guy Davies The store lacked guidance, policies, and risk assessments for cycling indoors, including a safe designated area and helmet use, creating an unsafe …	South West Cornwall and the Isles of Scilly	Halfords Group PLC	0/1
16 Aug 2017	Helen Cannon 2017-0260 · Jennifer Leeming Emergency responders failed to seek medical assistance for a patient with internal hemorrhage after a fall, misinterpreting her symptoms. A subsequent flawed …	North West Manchester (City)	Care Quality Commission Department for Community and Local … Department of Health and Social … Eldercare	1/5
8 May 2017	Maud Patrick 2017-0151 · Nigel Meadows Systemic hospital care failures included no mental capacity assessment, poor A&E handover, unprogressed investigations, inadequate patient observations, and insufficient staffing and senior …	North West Manchester (City)	Care Quality Commission Manchester Clinical Commissioning Group University of South Manchester Hospitals …	0/3
21 Aug 2017	Roger Hamer 2017-0259 · Peter Sigee Inadequate highway inspection practices failed to document carriageway deterioration, and a proposed new management procedure risks increasing deaths, particularly for cyclists, by …	North West Manchester (North)	Bury Metropolitan Borough Council Department for Transport	2/2
3 Oct 2017	Terrence George 2017-0253 · Emma Carlyon Most Trusts lacked local guidance for timely gallstone surgery post-pancreatitis despite international recommendations. Management did not prioritise this, indicating a need for …	South West Cornwall and the Isles of Scilly	N.I.C.E	0/1
6 Oct 2017	Jennifer Midgley 2017-0252 · David Hinchliff The drug administration chart fails to clearly distinguish between oral and intravenous paracetamol, lacks patient weight reference for IV dosage, and omits …	Yorkshire and the Humber West Yorkshire (East)	Mid Yorkshire NHS Trust	0/1
16 Aug 2017	Isabella Pritchard 2017-0261 · Peter Bedford The unregulated fireplace industry lacks safety standards, leading to inherently dangerous designs and vague installation instructions. Absence of building control for installation …	South East Berkshire	Department of Business, Energy and … Department of Communities and Local …	1/2
8 Sep 2017	Patricia Forshaw 2017-0262 · Alan Walsh The hospital discharge card provided ambiguous contact information, leading to incorrect telephone advice being given and unrecorded critical observations by staff. Despite …	North West Manchester (West)	Wrightington, Wigan and Leigh NHS …	1/1
31 Oct 2017	Vilhelmas Borkertas 2017-0342 · ME Hassell A bisexual prisoner was improperly celled with a homophobic cellmate despite clear risk assessment information, raising concerns about placing inmates with conflicting …	London London Inner (North)	HMP Pentonville	0/1
10 Oct 2017	Tahnie Martin Emma Whitting Past building inspections failed to identify unsafe roof structures or document access issues, leading to unmaintained hazards and a risk of future …	West Midlands Black Country	RICS ROYAL INSTITUE of CHARTERED SURVEYORS …	1/2
8 Sep 2017	Terence Ryan 2017-0225 · Alan Walsh The GP surgery failed to correctly add new anticoagulation medication to repeat prescriptions and lacked a formal protocol for discharge medications. The …	North West Manchester (West)	Grasmere Surgery Wrightington, Wigan and Leigh NHS …	2/2
11 Sep 2017	Geoffrey Taylor 2017-0226 · Emma Carlyon Limited DVLA mechanisms exist for medically reviewing elderly drivers with deteriorating health, and GPs face conflicts of interest in reporting, potentially leading …	South West Cornwall and the Isles of Scilly	Department for Transport Driver and Vehicle Licensing Agency	1/2
7 Sep 2017	Glenys Pollitt 2017-0228 · Alison Mutch Inconsistent use of high-resolution X-ray screens and clinician confirmation bias led to missed abnormalities. There were also unclear processes for reinforcing learning …	North West Manchester (South)	Stepping Hill Hospital	1/1
11 Sep 2017	Henry Prow 2017-0227 · Emma Carlyon Limited DVLA mechanisms exist for medically reviewing drivers with deteriorating health, and GPs face conflicts of interest in reporting, potentially leading to …	South West Cornwall and the Isles of Scilly	Department for Transport Driver and Vehicle Licensing Agency	1/2
7 Sep 2017	David Sewell 2017-0229 · Andrew Barkley There was a lack of a robust system to ensure mental health patients, especially those with psychotic episodes, were seen and re-engaged, …	Wales South Wales Central	Cwm Taff University Hospital Health …	1/1
11 Sep 2017	Brian Betterton 2017-0224 · Ian Pears Product recalls for items like fuse boxes are ineffective because end-users are often untraceable, as professional purchasers are not required to log …	East of England Bedfordshire and Luton	Department for Business, Energy and …	1/1
22 Sep 2017	Shahbaz Salim 2017-0237 · Andrew McNamara The collision scene is hazardous due to its tendency to accumulate standing water during rainfall and a gap in the vehicle restraint …	East Midlands Nottinghamshire	Highways England	1/1
28 Sep 2017	Gillian O’Keefe 2017-0233 · Angela Hodes The patient was illogically discharged from mental health care for "non-engagement" despite acute deterioration, without a multidisciplinary meeting or follow-up procedure for …	London London Inner (West)	Cricket Green Medical Practice Department of Health and Social … St George’s Mental NHS Trust	3/3
27 Sep 2017	Peter Kollar 2017-0234 · Andrew Harris Jaundice in children beyond the neonatal period is under-recognised by doctors. Non-escalation to specialists can adversely affect care and be life-threatening, especially …	London London Inner (South)	Royal College of Emergency Medicine Royal College of Paediatrics and …	1/2