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 224 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
8 Sep 2017	Melvin James 2017-0210-wp25845 · Zafar Siddique The hospital discharged a patient without adequate mental health assessment, failing to communicate with family about ongoing delusions or provide formal referral …	West Midlands Black Country	NHS Lothian Scotland	0/1
21 Sep 2017	Barbara Sturgess 2017-0209 · Peter Nielo The hospital failed to promptly and formally communicate a patient's cervical spinal fracture and necessary care measures to the nursing home and …	East Midlands Derby and Derbyshire	Ashgate House Nursing Home Chesterfield Royal Hospital	0/2
18 Sep 2017	Dennis Oldland 2017-0211 · Alan Wilson Care workers prematurely leaving visits based solely on task completion and apparent contentment risks overlooking potential welfare concerns due to insufficient interaction …	North West Blackpool and The Fylde	Safehands Ltd	0/1
18 Sep 2017	Kathleen Holme 2017-0212 · Robert Chapman The automatic air freshener lacked prominent warnings about fire risks near naked flames, with critical safety information being too small on packaging …	North West Cumbria	SC Johnson and Son	1/1
14 Sep 2017	David Lindsey 2017-0213 · Caroline Beasley-Murray The family contended that the trust did not follow NICE guidelines for cancer screening, referrals, diagnosis and treatment, and that the trust …	East of England Essex	Basildon and Thurrock University Hospital …	0/1
18 Sep 2017	Reginald Dixon 2017-0214 · Zafar Siddique An emergency call was incorrectly triaged, leading to a delayed response, compounded by insufficient resources and consistently slow ambulance attendance times, posing …	West Midlands Black Country	West Midlands Ambulance Service	1/1
13 Sep 2017	Bronwyn Williams 2017-0215 · ME Hassell An urgent dental referral was sent by slow postal service, and the subsequent maxillofacial appointment was significantly delayed for nearly seven weeks …	London London Inner (North)	Homerton University Hospital NHS Trust Kindandental	2/2
20 Jul 2017	Nina Maggs 2017-0216 · David Ridley The pedestrian crossing at the junction is unsafe due to a lack of signals, audible/vibrating assistance, and an insufficient all-red light phase, …	South West Wiltshire and Swindon	Department for Transport Swindon Borough Council	2/2
14 Aug 2017	Terence Pimm 2017-0217 · Caroline Beasley-Murray Deficiencies in police call handling, record-keeping, and inter-agency information sharing hampered risk assessment for individuals with mental health issues. Insufficient training also …	East of England Essex	Essex Partnership University NHS Foundation … Essex Community Rehabilitation Company Essex Police	2/3
11 Sep 2017	Janet Williams 2017-0218 · ME Hassell The patient's care plan was not on the computer system, leading to missed reviews and alerts. The care co-ordinator dismissed family concerns, …	London London Inner (North)	East London NHS Trust	0/1
26 Jul 2017	Songul Bozdag 2017-0219 · ME Hassell The care co-ordinator failed to conduct mandatory patient reviews, maintain accurate records, and update medication dosages, leading to under-medication, with no systemic …	London London Inner (North)	East London NHS Trust	1/1
17 Sep 2017	Paul Maddox 2017-0220 · Andre Rebello The hospital failed to implement identified strategies to address missed opportunities in acting on reducing haemoglobin trends, demonstrating a critical delay in …	North West Liverpool and Wirral	Wirral University Hospital Trust	1/1
12 Sep 2017	Frances Greenhalgh 2017-0221 · Alan Walsh A GP surgery failed to properly record and integrate a crucial treatment plan notification from the RAID Team into the patient's medical …	North West Manchester (West)	Heaton Medical Centre	0/1
11 Sep 2017	John Griffiths 2017-0222 · Nigel Meadows The Emergency Department lacked a system to check patients' recent attendances or access previous medical records and investigation results, leading to missed …	North West Manchester (City)	Comish Way Group Practise UHSM	1/2
11 Sep 2017	Brian MaClean 2017-0223 · Nigel Meadows Social Services and housing providers failed to proactively assess fire risks, make referrals to fire services, or install automatic water suppression systems …	North West Manchester (City)	Great Places Housing Association Director of Housing Department for Adult Social Services NHS Manchester Clinical Commissioning Group	1/4
16 Jun 2017	Dianne Macrae 2017-0193 · Anne Pember The coroner noted that the consultant spinal surgeon was not contacted promptly, the patient's haemoglobin level was not obtained, and internal haemorrhage …	East Midlands Northamptonshire	Department of Health and Social … Kettering General Hospital Nursing and Midwifery Council Royal College of Anaesthetists	4/6
13 Sep 2017	Sam Molyneux 2017-0340 · Andre Rebello Old prison wings lacking anti-barricade doors delayed emergency access, and a prisoner with documented self-harm threats was not placed on an appropriate …	North West Liverpool & Wirral	HM Prison & Probation Service	1/1
25 Apr 2017	Linsay Bushell 2017-0137 · Andre Rebello A significant lack of provision and priority for commissioning therapeutic psychological services for mentally disordered female patients with Emotionally Unstable Personality Disorder …	North West Liverpool and Wirral	Department for Health NHS England	1/2
27 Jun 2017	Dean Rowland 2017-0208 · Margaret Jones Delays in accessing GP appointments for antidepressant review and premature discharge from community mental health services, despite previous serious suicide attempts, posed …	West Midlands Staffordshire (South)	Peel Medical Practice South Staffordshire and Shropshire Healthcare …	2/2
25 May 2017	Bonamie Armitage 2017-0170 · Katy Skerrett There are no mandatory requirements for child participants in a Hunt to wear protective equipment, demonstrate competence, or have adult supervision with …	South West Gloucestershire	Cotswold Hunt Council of Hunting the Masters of Foxhounds Association	1/3