Penelope Benton
AI-generated concerns summaryThe General Practitioner was not made aware of a previous tramadol overdose as this information was omitted from the hospital discharge letter.
Addressed to: Dudley and Walsall Mental Health NHS Trust
Source · Prevention of Future Deaths
Prevention of Future Deaths Reports
Browse 6,488 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
Dorothy Breislin
AI-generated concerns summaryConcerns were raised regarding the significant delay in providing the Incident Review Report and the family's assertion that they never received an apology. Additionally, it was noted that none of the proposed action plan items have been implemented since the incident date.
Addressed to: Lincolnshire Hospitals NHS Trust
Peter Cotter
AI-generated concerns summaryThe clinical decision support software system did not register a head injury for a patient receiving anticoagulant drugs. The coroner recommends reviewing the triage system to ensure all head injuries are recognised and treated as emergencies.
Addressed to: South Central Ambulance Service NHS Trust
Liam Thomas
AI-generated concerns summaryThe coroner raised concerns regarding a patient's access to restricted plastic bags and the effectiveness of environmental checks. There was also a need for improved communication between staff and the patient's family, particularly concerning elevated risk information.
Addressed to: Oxford Health NHS Trust
Darren Powney
AI-generated concerns summaryThe coroner noted staff confusion regarding an existing ambulance protocol and that dynamic risk assessments did not facilitate crews requesting further information. Concerns were also raised about the absence of bespoke policies for frequent callers and delays in implementing new protocols and training.
Addressed to: North East Ambulance Service NHS Trust
Scott Rayner
AI-generated concerns summaryThe coroner noted inadequate fencing beside the railway track, particularly behind a scrap metal dealer, which creates a risk of trespass onto a high-speed railway line by adults and children.
Addressed to: Network Rail
John Nichols
AI-generated concerns summaryThe Fire Drills Policy did not include sufficient safeguards for monitoring residents, particularly those with dementia, before, during, and after fire drills.
Addressed to: Eastgate Residential Care Homes; King's Lynn Residential Care Homes
William Bergman
AI-generated concerns summaryThe coroner identified concerns regarding a staff nurse's assessment and management of a head injury, noting the absence of immediate observations, a medical review, and recognition of potential serious consequences for an elderly patient with existing health conditions.
Addressed to: Barts Hospital NHS Trust
Andrew Finlay
AI-generated concerns summaryThe coroner expressed concern regarding the timely despatch and arrival of ambulance crews for 999 calls, noting that 32 paramedic vacancies remained unfilled a year after the death.
Addressed to: North East Ambulance Service NHS Foundation Trust
Caliel Smith-Kwami
AI-generated concerns summaryDelayed insulin results and a lack of clinician notification about analyser faults were identified, alongside critical test results not being chased up or highlighted within the electronic record system before discharge.
Addressed to: Barts Health NHS Trust
Lee Daniel
AI-generated concerns summaryThe coroner noted concerns regarding the absence of double yellow lines in a 20-meter section of Coach Lane, Brading. This allowed vehicles to park, obstructing visibility and requiring drivers to cross onto the wrong side of the road.
Addressed to: Isle of Wight Council Highways Department
Mark Welsh
AI-generated concerns summaryThe coroner raised concerns about Transport for London's significant delays in implementing pedestrian safety improvements at a busy crossroads and its accident statistics methodology, which did not account for overall incident incidence or near misses.
Addressed to: Transport for London
Ernest Smith
AI-generated concerns summaryConcerns persist regarding the system for considering GP correspondence, including medication review requests, which remains unchanged. Additionally, there is no clear system for updating GPs on patient progress or disengagement when care is led by non-medical multidisciplinary teams.
Addressed to: Surrey and Borders Partnership NHS Trust
Ronald Farrington
AI-generated concerns summaryThe coroner noted Nuffield Care Centre's failure to follow tissue viability nurse advice, maintain accurate records, and refer a patient to a GP for infection. Concerns also arose regarding insufficient tissue viability nurse staffing, inadequate CQC evidence collection, and lack of family involvement in reviews.
Addressed to: Surrey First Community Health Care; Care Quality Commission; Saffronland Homes limited; Surrey County Council
Timothy Atkins
AI-generated concerns summaryThe coroner noted a shared cycle/pedestrian pavement corner that was a narrow pinch-point with poor visibility and no safety barrier, raising concerns for cyclist and pedestrian safety.
Addressed to: Portsmouth City Council
Harminder Dhillon
AI-generated concerns summaryThe level crossing lacks CCTV monitoring, which may contribute to unreported misuse. The coroner identified that the half barrier system is an insufficient deterrent, noting that a full-length barrier could prevent future deaths.
Addressed to: Network Rail
Jeremy Marshall
AI-generated concerns summaryThe coroner noted concerns regarding the expectations for junior doctors and delays in contacting senior clinicians for deteriorating patients. There was also a lack of clear instructions for nursing staff and specific timescales within patient care plans.
Addressed to: Great Western Hospital NHS Trust
Andrew Codling
AI-generated concerns summaryA community health team's voicemail message to the deceased was too brief, stating the office was closing and advising to call back Monday, thus missing an opportunity to reinforce alternative help and crisis numbers for immediate support.
Addressed to: East London NHS Trust
Naomi Sourbut
AI-generated concerns summaryThe coroner noted it was unclear whether recommendations from a root cause analysis regarding clients expressing suicidal ideation had been implemented by Devon Partnership Trust, and that protective factors should be in place for individuals indicating intent and means to cause harm.
Addressed to: Devon Partnership Trust
Fallon Abby
AI-generated concerns summaryThe Roman Ward team did not contact the patient's social worker due to a lack of protocol, resulting in missed opportunities to share valuable information and ensure the social worker's support upon discharge.
Addressed to: East London NHS Trust