Source · Prevention of Future Deaths

Prevention of Future Deaths Reports

Browse 6,383 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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6,383 reports · Page 227 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
5 Jun 2017	David Hamilton 2017-0180 · Alison Mutch Healthy Minds lacked documentation for therapy selection, clarity on referral triggers, and a formal escalation process for concerns. Limited information sharing between …	North West Manchester (South)	Grosvenor Medical Centre Stalybridge Pennine Care NHS Trust	2/2
6 Jun 2017	George Cheese 2017-0179 · Peter Bedford A patient with known suicidal thoughts was prescribed a large quantity of antidepressant medication. There was no system or "flag" in their …	South East Berkshire	Woodley Centre Surgery	1/1
1 Jun 2017	Terry Latimer 2017-0178 · Paul Kelly A safeguarding notice with a request for Mental Health Services referral was not actioned. There was a lack of clarity among staff …	Yorkshire and the Humber North Lincolnshire and Grimsby	North Lincolnshire Council	0/1
24 May 2017	Dominic White 2017-0177 · ME Hassell A robust protocol is lacking to ensure all personnel are aware of patient observation levels. An approved mental health professional showed a …	London London Inner (North)	Barnet, Enfield and Haringey Mental … Camden and Islington NHS Trust Whittington Health NHS Trust	1/3
30 May 2017	Sarah Poole 2017-0176 · Zafar Siddique There were failures to record the reviewing doctor for an ECG and to account for previous abnormal ECG results during patient handover …	West Midlands Black Country	Royal Wolverhampton NHS Trust	1/1
30 May 2017	Kenneth Evans 2017-0175 · Zafar Siddique Thromboprophylaxis was not arranged, and an effective risk assessment for developing blood clots was not undertaken for the patient.	West Midlands Black Country	Dudley Group of Hospitals NHS …	1/1
1 Jun 2017	Michael Halfpenny 2017-0174 · Lydia Brown A GP referral for vascular screening was sent to the wrong department and refused, with no follow-up. Both GP practice and hospital …	East Midlands Leicester City and Leicestershire South	East Leicestershire and Rutland Clinical … The Glenfield Surgery University Hospitals of Leicester NHS …	3/3
31 May 2017	Jonathan Palmer 2017-0173 · Kevin McLoughlin There was no effective system for families to provide crucial health information for prisoners, nor assurance of its dissemination. Ineffective control of …	London London Inner (West)	HMP Wandsworth Home Office	1/2
28 May 2017	Jamie Pashley 2017-0172 · Julian Morris The system over-relied on individuals proactively managing their rehabilitation post-detoxification. Concerns included a lack of fixed appointments, follow-up calls, and limited availability …	London London Inner (South)	Department of Health and Social … King's College Hospital NHS Foundation … South London and Maudsley NHS …	1/3
28 Jul 2017	Sarah Reed 2017-0238 · Sir Peter Thornton QC Prolonged custody awaiting psychiatric reports led to significant deterioration of the deceased's mental health in a prison assessment unit, resulting in her …	London London (City)	Central and North West London … HM Courts and Tribunals Service HM Prison and Probation Service Ministry of Justice	2/4
5 Apr 2017	Ronald Bennett 2017-0097 · Gilva Tisshaw There are serious delays in ambulances arriving at the scene of an incident.	South East Brighton and Hove	Brighton and Sussex University Hospitals … SECAMB	2/2
19 Jan 2017	Thomas Coyne 2017-0207 · John Pollard Inadequate CCTV coverage at the station and the absence of physical barriers at platform ends allowed unmonitored access to the tracks, posing …	North West Cheshire	Northern Rail	0/1
28 Jun 2017	Olaseni Lewis 2017-0205 · Selena Lynch Police training on restraint techniques and Acute Behavioural Disturbance (ABD) was inadequate and misunderstood, leading to officers misinterpreting risks, especially regarding "prolonged …	London London (South)	Metropolitan Police Service South London and Maudsley NHS …	2/2
22 Jun 2017	Aston Soulsby 2017-0204 · Zafar Siddique Pedestrians waiting in hatched road areas and vehicles passing in these zones create confusion and significant risk of road traffic incidents.	West Midlands Black Country	Sandwell Local Authority	1/1
23 Jun 2017	Robert Cardwell 2017-0203 · Rachel Galloway Significant communication failures prevented crucial patient information from reaching the multi-disciplinary team, leading to inappropriate discharge and a lack of follow-up care …	North West Preston and East Lancashire	Lancashire Care NHS Foundation Trust	0/1
7 Jun 2017	Dennis Teesdale 2017-0202 · Karen Henderson The hospital lacked specialist facilities and clinicians for complex procedures like PEG insertion. Written guidance was not followed, and no risk assessment …	South East West Sussex	Care Quality Commission Department of Health, NHS England Queen Victoria NHS Trust	3/3
22 Jun 2017	Constance Connolly 2017-0201 · Andrew Harris The report describes failures in the handover of patients needing urgent follow-up, including a doctor not following up on a scan they …	London London Inner (South)	King's College Hospital NHS Foundation …	2/1
21 Jun 2017	Colin Sluman 2017-0200 · Elizabeth Earland Emergency call handling protocols inadequately categorised severe symptoms like "dizziness" for rapid response, compounded by a lack of clinical training and insufficient …	South West Exeter and Greater Devon	NHS England South Western Ambulance NHS Foundation …	2/2
16 Jun 2017	Katherine Derbyshire 2017-0199 · Timothy Brennard Inadequate communication between hospitals, delayed transfer for critical dialysis, and a lack of a clear plan for patient deterioration led to missed …	North West Manchester (West)	Salford Royal Hospital Royal Albert Edward Infirmary	2/2
14 Jun 2017	Ellie Chappell 2017-0198 · Nicola Mundy The absence of warning signs on a road stretch with a high incidence of accidents due to slippery conditions poses an ongoing …	Yorkshire and the Humber South Yorkshire (East)	Doncaster County Council	1/1