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 226 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
3 May 2017	Margaret Conway 2017-0145 · David Hinchliff Systemic separation of mental and physical health services led to challenging patient transfers and fragmented care for individuals with co-occurring serious mental …	Yorkshire and the Humber West Yorkshire (East)	Mid Yorkshire NHS Trust South West Yorkshire NHS Trust	0/2
2 May 2017	Ida Toole 2017-0146 · Thomas Osborne A high falls risk patient was denied a sensor mat based on mental capacity, demonstrating a policy requiring urgent review for potentially …	South East Milton Keynes	Excel Care	0/1
2 May 2017	Daniel Dunkley 2017-0147 · Thomas Osborne The report notes that three referrals were made for Mr Dunkley to undergo a full mental health assessment before his death.	South East Milton Keynes	HMP Woddhill	0/1
3 May 2017	Rayan Ahmed 2017-0148 · Maria Voisin Inadequate handover procedures in the special care unit mean nurses may care for unfamiliar babies during breaks, highlighting a need for comprehensive …	South West Avon	North Bristol NHS Trust	0/1
4 May 2017	Reginald Lewis 2017-0149 · Zafar Siddique Inadequate patient supervision, staff unawareness of visitor departures, and overcrowded wards with pressured junior staff accepting high-needs patients created an unsafe care …	West Midlands Black Country	NHS Foundation Trust New Cross Hospital	0/2
4 May 2017	Muriel Brett 2017-0150 · Andrew Cox There are conflicting expert opinions regarding a potentially defective cardiac valve, with the operating surgeon identifying a defect not confirmed by an …	South West Plymouth Torbay and South Devon	MRHA	0/1
13 Jun 2017	Craig Hamilton 2017-0197 · Nicola Mundy A lack of clear procedures to manage patients routinely obtaining or exceeding prescribed medication dosages, or to discuss alternative pain management, poses …	Yorkshire and the Humber South Yorkshire (East)	Manor Field Surgery	1/1
16 Jun 2017	Lee Swain 2017-0196 · Anita Bhardwaj A lack of coordinated procedures for transferring mental health patients between NHS Trusts, exacerbated by exiting a Care Programme Approach, resulted in …	North West Liverpool and Wirral	Chester Hospital NHS Trust Mersey Care NHS Trust Cheshire Wirral Partnership	0/3
16 Jun 2017	Aaron McCaffrey 2017-0195 · Rachel Galloway The lack of purchase limits for loperamide medication at retail stores enables bulk buying, increasing the risk of addiction and overdose.	North West Manchester (South)	Medicines and Healthcare products Regulatory …	0/1
14 Jun 2017	Rasikaben Chauhan 2017-0194 · Hassan Shah There is a lack of clear communication and awareness-raising regarding a specific risk with relevant community and religious organisations.	East Midlands Nottingham	Asra Housing Group - Nazarana … Chief Fire and Rescue Officer Indian Hindu Welfare Organisation	1/3
13 Jun 2017	Russell Sherwood 2017-0192 · Philip Spinney The Fire Service departed a dangerous flood scene without closing the road or leaving warning signs, as their protocols and equipment do …	Wales South Wales Central	South Wales Fire and Rescue …	1/1
15 Jun 2017	Lily Townsend 2017-0191 · Zafar Siddique Failures in preoperative assessment, including incomplete medical history and inadequate use of care bundles, led to a high-risk patient undergoing surgery without …	West Midlands Black Country	Sandwell and West Birmingham Hospitals …	1/1
15 Jun 2017	Kevin Mann 2017-0190 · Nadia Persaud A medical procedure was inappropriately performed despite clear radiological contraindications and continued after complications, compounded by the radiologist's failure to check prior …	London London(East)	Barking, Havering and Redbridge University …	1/1
14 Jun 2017	Alaanuloluwa Joseph 2017-0189 · Sean Cummings Inaccurate monitoring and recording of fluid intake and output, a critical aspect of sepsis management, was not undertaken.	London London (West)	Hillingdon Hospitals NHS Trust	0/1
14 Jun 2017	Maurice Macdonnell 2017-0188 · Andrew Harris A potential conflict of interest arose when a doctor, also a research investigator, administered a second drug dose despite adverse effects, raising …	London London Inner (South)	Medicines and Healthcare products Regulatory …	1/1
12 Jun 2017	William Wilson 2017-0186 · Christopher Murray The establishment lacked a clear system for alerting the designated first aider, and staff who attended the deceased were unfamiliar with basic …	North West Manchester (South)	Church Inn	0/1
7 Jun 2017	Callum Smith 2017-0185 · Maria Voisin There was a conflict in risk assessment methods for suicide/self-harm between healthcare staff and ACCT policy for prisoners. Staff required clearer guidance …	South West Avon	Avon and Wiltshire Mental Health … Bristol Community Health HMP Bristol	1/3
6 Jun 2017	Joyce Rumming 2017-0182 · David Ridley Poor communication between software packages meant an allergic marker for Amoxicillin was missed, leading to the patient being administered a drug they …	South West Wiltshire and Swindon	Great Western Hospitals NHS Trust	1/1
5 Jun 2017	Jack Braniff 2017-0183 · Catherine McKenna The coroner raises concerns that the size and position of an illuminated advertising board obstructs views for pedestrians and drivers, and that …	North West Manchester (North)	Highways England Oldham Council	1/2
2 Mar 2017	Paul Barber 2017-0184 · Veronica Hamilton-Deeley The report indicates a risk of future deaths unless action is taken, but no specific concerns were detailed in the provided text.	South East Brighton and Hove	Brighton and Sussex University Hospitals …	1/1