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.
Reports
| Date | Report | Responses identified |
|---|---|---|
| 26 Sep 2017 |
Hedley Greenland
2017-0235 · Andrew Barkley
Nursing staff failed to use a fluid balance chart or monitor urine output, hindering detection of critical issues. A nurse was untrained …
|
1/2 |
| 26 Sep 2017 |
Rodney Hampshire
2017-0236 · Jennifer Leeming
The surgical ward currently lacks monitored beds, which a review suggests could potentially save lives by improving patient surveillance.
|
1/1 |
| 21 Sep 2017 |
Margaret Pine
2017-0239 · John Tomalin
The absence of "no through road" signs at the start and reflective warnings at the dead-end wall risks drivers reaching a sudden, …
|
1/1 |
| 4 Sep 2017 |
Francis Langley
2017-0240 · David Ridley
Inconsistent and contradictory falls risk assessments, differing between hospital departments, failed to properly assess the patient's risk, leading to bed rails not …
|
1/1 |
| 4 Sep 2017 |
Anthony McCormack
2017-0241 · Fiona Borrill
Airline staff training in cardiac arrest recognition and CPR was inadequate, while ambulance services failed to meet response targets, exacerbated by only …
|
2/5 |
| 27 Jul 2017 |
Liam Hall
2017-0242 · Karen Dilks
A lack of appropriate warning signage about water risks, especially with inflatables, and no lifeguard supervision contributed to the death in Roker …
|
0/1 |
| 1 Sep 2017 |
Mohammad Ashraf
2017-0243 · Louise Hunt
Inaccurate and delayed care plans, poor communication between the school and catering service, and a failure to disseminate critical safety recommendations by …
|
2/4 |
| 24 Aug 2017 |
Jonathan Meaney
2017-0244 · ME Hassell
Prolonged waiting for a mental health bed and a flawed discharge assessment, where overdose intent was not adequately addressed, resulted in the …
|
2/2 |
| 29 Aug 2017 |
Shaun Carter
2017-0245 · Caroline Saunders
Dumper truck safety procedures were not followed, understood by all personnel, or audited. There was also a lack of industry standards for …
|
1/2 |
| 29 Aug 2017 |
Beryl Goode
2017-0246 · Ian Pears
Care home night staff, lacking medical training, failed to consider a head injury as the cause of a resident's confusion after a …
|
0/1 |
| 24 Aug 2017 |
Joseph Tarnowski
2017-0247 · Chris Morris
A resident was unable to effectively use a call-bell due to potential unawareness of its portability or mobility limitations, highlighting a lack …
|
1/1 |
| 21 Aug 2017 |
Francesca Whyatt
2017-0248 · Karon Monaghan
Key safety gaps include no risk assessment for ward configuration, inadequate guidance on agency staff observation competency, and the failure to automatically …
|
1/4 |
| 11 Aug 2017 |
Milan Dokic
2017-0249 · Russell Caller
London's Cycle Super Highways and roads suffer from inadequate systems for determining and monitoring grip levels. Urgent research is needed on scientific …
|
1/1 |
| 21 Aug 2017 |
Jac Davies
2017-0250 · Aled Gruffydd
Landlords in Wales are under no legal obligation to install smoke alarms in rented properties, contrasting with England's regulations, and current "best …
|
1/1 |
| 6 Sep 2017 |
Jeffery Matthews
2017-0230 · Kally Cheema
Inadequate warning signage and obstructed visibility at a hazardous crossroads, combined with a failure to implement previously recommended safety improvements due to …
|
1/1 |
| 6 Sep 2017 |
Brandon Singh Rayat
2017-0231 · Dianne Hocking
There is a critical lack of long-term mental health care provision for children in Leicestershire who cannot attend hospital due to anxiety, …
|
2/2 |
| 11 Jul 2017 |
Mark Berry
2017-0232 · Karen Harold
Hospital staff delayed police notification of a suspicious death due to procedural confusion. Additionally, ambulance handover and private ambulance communication lacked critical …
|
0/2 |
| 28 Sep 2017 |
Katherine Vanloo
2017-0493 · John Buckley
There was a severe 7-month delay in pothole repair, exacerbated by the County Council's lack of a system to track works orders …
|
1/1 |
| 28 Sep 2017 |
Conall Gould
2017-0458 · Emma Brown
The patient and carers were not informed of a crucial follow-up mental health appointment post-discharge, as the Trust lacked a policy requiring …
|
1/1 |
| 8 Sep 2017 |
Anne-Marie James
2017-0210 · Zafar Siddique
A missed opportunity in hospital-family communication meant clinicians were unaware of the patient's ongoing delusions, leading to discharge without formal mental health …
|
0/1 |