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 229 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
25 Apr 2017	Jamie Elliott 2017-0135 · Edwin Buckett Mental health clinicians failed to contact external providers when patients received treatment elsewhere. There was also a lack of timely, face-to-face consultant …	London London Inner (North)	East London NHS Foundation Trust	1/1
25 Apr 2017	Joleen Linton 2017-0136 · Jason Pegg Concerns about inadequate and unreliable hourly patient observations due to environmental factors, inaccurate record-keeping, undetected errors, staff reluctance to enter rooms, and …	West Midlands Coventry	Coventry & Warwickshire Partnership NHS …	0/1
26 Apr 2017	John Davies 2017-0138 · Alison Mutch There was no risk assessment plan when the resident's needs changed from care to nursing, the District Nursing Team was unaware of …	North West Manchester (South)	Stockport NHS Foundation Trust	1/1
18 Apr 2017	David Birtwistle 2017-0139 · Terence Moore A patient diverted from A&E meant crucial tests for pulmonary embolism were missed, compounded by unavailable 111 referral information at the emergency …	South West Avon	Brisdoc NHS, University Hospital Bristol NHS …	0/2
6 Jul 2017	Rose Workman 2017-0435 · Katy Skerrett The district nursing service's measures for effectively monitoring patients' ongoing conditions are questioned as potentially insufficient.	South West Gloucestershire	Gloucestershire Care Services NHS Trust	1/1
6 Jul 2017	Cameron Chadwick 2017-0436 · Jennifer Leeming A pothole exceeding the minimum depth for repair was present in the carriageway, contributing to a fatal accident.	North West Manchester (West)	Wigan Council	1/1
6 Jul 2017	John Ramsden 2017-0437 · Jennifer Leeming Inadequate family consultation occurred, as only one of three daughters was involved in critical end-of-life care decisions, including hospital admission.	North West Manchester (West)	Agrade Community Care Services	0/1
5 Jul 2017	Roy Lynch 2017-0431 · Eleanor McGann The highway design lacked stopping restrictions at a dangerous location, despite a nearby safe parking area, creating an unacceptable risk for drivers …	East of England Essex	Essex Highways	0/1
5 Jul 2017	Patricia Norfolk 2017-0438 · Julie Robertson Patients lacked daily senior clinician reviews, raising concerns about the standard of care provided during the interim period before new staff can …	North West Manchester (North)	Pennine Acute NHS Trust	0/1
4 Jul 2017	Janet Muller 2017-0441 · Penelope Schofield Deficient nursing records, risk assessments, and care plans, coupled with inadequate staffing and persistent issues allowing Mental Health Act patients to abscond, …	South East West Sussex	Sussex Partnership NHS Trust	1/1
3 Jul 2017	Joseph De Pellergrino-Farrugia 2017-0430 · Robert Turnbull The absence of safety sensors on a chair mechanism led to a crushing injury, as it failed to detect a foot's presence …	Yorkshire and the Humber North Yorkshire (West)	A.J Way & Co Ltd National Trading Standards Yorkshire Care Equipment	1/3
3 Jul 2017	Sheila Hynes 2017-0448 · Karen Dilks A mechanical aortic valve was remounted against manufacturer instructions by an untrained scrub nurse, without recorded discussion or awareness of associated risks …	North East Newcastle Upon Tyne	Newcastle Upon Tyne NHS Trust	0/1
28 Jun 2017	David Lee 2017-0432 · Julie Robertson The inappropriate termination of an emergency call, due to uncirculated guidance and lack of training, led to a missed opportunity to escalate …	North West Manchester (North)	North West Ambulance Service NHS …	0/1
26 Jun 2017	Jonathan Zucker 2017-0433 · Andrew Walker A lack of a lead clinician or systemic coordination between private and NHS mental health services resulted in fragmented patient care oversight.	London London (North)	Department of Health and Social … Royal College of Psychiatrists	2/2
19 Jun 2017	Patrick Woods 2017-0434 · Ian Pears The hospital's unknown equipment portfolio prevented the identification of potentially dangerous devices, hindering proper risk assessments and actions to prevent patient injury …	East of England Bedfordshire and Luton	DAC Beachcroft LLP Drager Luton & Dunstable University Hospital …	2/3
20 Apr 2017	David Evans 2017-0134 · Philip Spinney An untrained doctor performed a FAST ultrasound without supervision, and records were not stored. There was also inadequate escalation of care for …	Wales South Wales Central	Cardiff and Vale University Health …	0/1
24 Apr 2017	Barry Hodges 2017-0133 · Sarah Slater Ambulance dispatch protocols were not followed, leading to unused resources and breached timescales without escalation. There was also a lack of staff …	Yorkshire and the Humber South Yorkshire (East)	Yorkshire Ambulance Service NHS Trust	1/1
21 Apr 2017	Najeeb Katende 2017-0132 · Edwin Buckett There were failures to actively cross-check for shockable rhythms and to routinely use defibrillators in AED mode during cardiac arrest incidents, highlighting …	London London Inner (North)	London Ambulance Service NHS Trust	0/1
19 Apr 2017	Elaine Talbot 2017-0131 · Lisa Hashmi General practitioners lacked direct urgent access to CT scanning, unlike those in neighboring areas. This commissioning issue risks delaying diagnoses and potentially …	North West Manchester (North)	Bury Clinical Commissioning Group	0/1
20 Apr 2017	Patricia Webb 2017-0130 · Veronica Hamilton-Deeley Inadequate fall prevention measures included insufficient observations, failure to identify fall patterns, and a lack of recorded meaningful activities. Unsuitable non-slip footwear …	South East Brighton and Hove	Brighton and Sussex University Hospitals …	0/1