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 225 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
26 May 2017	Doreen Miller 2017-0169 · David Ridley A safeguarding referral was improperly signed off by Wiltshire Council without investigation, and crucial cognitive assessment information was missing from the hospital …	South West Wiltshire and Swindon	Chippenham Community Hospital Great Western NHS Hospital Trust Wiltshire Health & Care Wiltshire Council	0/4
26 May 2017	Lucy Goldstone 2017-0168 · Fiona Borrill There are no Automated Electronic Defibrillators (AEDs) available on trams or at tram stops across the Metrolink network.	North West Manchester (City)	Department for Transport Department of Health and Social …	0/2
25 May 2017	Daphne Williams 2017-0167 · John Gittins Persistent issues with ambulance delays, emergency department admissions, resource availability, and patient flow continue to place patients' lives at risk despite previous …	Wales North Wales (East and Central)	Betsi Cadwaladr University Health Board HM Stanley Site Welsh Ambulance Services NHS Trust Ysbyty Gwynedd	1/4
23 May 2017	Robert Mullis 2017-0166 · Patricia Harding A vulnerable, partially sighted patient with dementia was able to disembark a high-speed train unaccompanied and access railway tracks directly from the …	South East Kent (Central and South East)	Network Rail South Eastern Railways	1/2
22 May 2017	Kevin Morgan 2017-0165 · Thomas Osborne There was no effective follow up by social services and the housing team, a safeguarding alert was not properly addressed, and a …	South East Milton Keynes	Milton Keynes Council	1/1
19 May 2017	Kate Dolby 2017-0164 · Heidi Connor Chronic underfunding and staff shortages in mental health services, particularly for doctors in the EIP team, led to precarious patient care and …	East Midlands Nottinghamshire	Nottingham Clinical Commissioning Group	0/1
25 Aug 2017	Sam Crick 2017-0457 · David Heming Missed neuroradiological findings and a critical report's unavailability to the neurosurgeon led to undetected brain herniation and rising intracranial pressure. The absence …	East of England Cambridgeshire and Peterborough	Barking, Havering and Redbridge NHS … Care Quality Commission NHS England	3/3
18 May 2017	Alice Gibson-Watt 2017-0163 · Sarah Ormond-Walshe A recurring failure to identify and appropriately escalate acutely physically unwell patients in mental health settings, compounded by insufficient vital sign monitoring …	London London (West)	NHS England	1/1
10 May 2017	Peter Richardson 2017-0162 · Simon Wickens A lack of formal guidance on safe tolerances for critical elements of two-post vehicle lifts and insufficient torque specifications from suppliers creates …	South East Surrey	Garage Equipment Association Health and Safety Executive HSB Engineering Insurance Services Limited Liftmaster Ltd	2/7
17 May 2017	William Wilkes 2017-0161 · Thomas Osborne Hospital discharge procedures are unacceptably slow, taking weeks rather than days, highlighting a need for a more efficient local protocol between the …	South East Milton Keynes	Clinical Commissioning Group for Milton … Milton Keynes University Hospital	1/2
17 May 2017	Lilly Baxandall 2017-0160 · John Gittins Persistent, unresolved systemic issues, including ambulance handover delays, emergency department overcrowding, and bed blocking, continue to recur despite previous warnings, placing patients' …	Wales North Wales (East and Central)	Betsi Cadwaladr University Health Board Conway County Council Denbighshire County Council Flintshire County Council	1/7
15 May 2017	Blaise Alvares 2017-0157 · Nicholas Rheinberg This was at least the second fatality attributable to a Bio Ethanol burner, with previous accidental injuries also reported.	South West Wiltshire and Swindon	Chief Fire Officer’s Association	0/1
15 May 2017	Sharon Soares 2017-0157-wp25813 · Nicholas Rheinberg There have been multiple fatalities and numerous accidental injuries linked to Bio Ethanol burners, indicating an ongoing and significant product safety risk.	South West Wiltshire and Swindon	Chief Fire Officer’s Association	0/1
15 May 2017	Stephen Leven 2017-0158 · R Brittain The lack of access for secondary care to crucial GP patient information, specifically a haemophilia diagnosis, poses a significant risk of future …	London London (North)	Department of Health and Social …	1/1
15 May 2017	Howard Jeffers 2017-0115 · R Brittain The inability to accurately analyze and detect novel psychoactive substances (NPS) through toxicological testing poses an ongoing risk of future deaths.	London London (North)	Pharmaceutical Chemistry, Drug Misuse and …	3/1
16 May 2017	Ruth Milne 2017-0156 · Paul Cooper Concerns about the lack of continuity and appropriateness of GP medical staff, and whether vital recommendations from a 2015 safeguarding report have …	East Midlands South Lincolnshire	Lincolnshire Community Health Service NHS … Lincolnshire Register Office	1/2
20 Apr 2017	Charlotte Agnew 2017-0141 · Alison Hewitt The report describes failures in the transfer of care, suicide risk assessment, care planning, medication management, and response to a request for …	London London (City)	North NHS Trust	0/1
27 Apr 2017	Anton Kusz 2017-0140 · Andrew Barkley An eight-hour ambulance delay for a patient with a fractured hip was caused by insufficient clinician capacity for 999 calls and widespread …	Wales South Wales Central	ABMU Health Board Welsh Ambulance Trust	1/2
30 Apr 2017	Ahsiyah Bibi 2017-0142 · Emma Brown Critical blood gas results were lost, delaying treatment. A significant insulin prescribing error occurred due to clinicians confusing doses, exacerbated by inadequate …	West Midlands Birmingham and Solihull	Heart of England NHS Trust	0/1
3 May 2017	Beryl Varcoe 2017-0144 · Anna Crawford Community alarm installation officers may not have thoroughly range-tested devices, risking alarms not functioning throughout clients' homes, affecting a significant number of …	South East Surrey	Elmbridge Borough Council	0/1