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 230 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
20 Apr 2017	Sian Hollands 2017-0129 · Roger Hatch Concerns include inadequate training on patient scoring systems, a failure to provide doctors with nurses' medical notes, and doctors' failure to correctly …	South East North West Kent	Dartford and Gravesend NHS Trust	0/1
20 Apr 2017	Errol Mann 2017-0128 · Nadia Persaud The Intensive Care Unit experienced severe and persistent staffing shortages, including Clinical Fellows, which directly compromised patient care and diverted consultant time …	London London (East)	Barts Health NHS Trust	0/1
20 Apr 2017	Harold Mullins 2017-0127 · Andrew Barkley The surgical team was unaware of the patient's thrombosis history. Deteriorating NEWS scores did not trigger timely clinician review, highlighting a failure …	Wales South Wales Central	Cwm Taf Morgannwg University Health …	0/1
20 Apr 2017	Thomas Whitfield 2017-0126 · Andrew Tweddle Family-reported suicide risks were not documented or acted upon by hospital staff. The absence of monitored or recorded patient telephone calls prevented …	North East County Durham and Darlington	Tees, Esk and Wear Valley …	0/1
20 Apr 2017	Johan Pambou 2017-0125 · Louise Hunt The GP practice lacked an adequate system to action hospital letters, leading to missed vaccinations. Concerns were also raised about the availability …	West Midlands Birmingham and Solihull	NHS England	1/1
18 Apr 2017	Daniel Maher 2017-0124 · Anna Crawford Critical information sharing failures exist between inter-county mental health services, with professionals unable to access out-of-county patient records or routinely share s.136 …	South East Surrey	Surrey and Borders Partnership NHS … West Sussex County Council	0/2
13 Apr 2017	Michael Newell 2017-0123 · James Adeley Junior medical staff lacked awareness of liver failure's impact and early hypovolaemia, delaying critical treatment and consultant input. Inadequate nursing procedures and …	North West Preston and West Lancashire	Lancashire Teaching Hospitals NHS Trust	0/1
13 Apr 2017	Daniel Campbell 2017-0122 · Tony Brown Broken and disrepaired fencing separating a public footpath from the railway line created easy opportunities for impulsive trespass, increasing the risk of …	North East North Northumberland	Network Rail	1/1
13 Apr 2017	Luke Moulding 2017-0121 · Ian Pears A critical "opt-in" follow-up letter was not sent after a psychiatric consultation, and the current system of typing letters rather than using …	East of England Bedfordshire and Luton	East London NHS Trust	1/1
12 Apr 2017	Chadrack Mulo 2017-0120 · ME Hassell School procedures for unexplained absences were inadequate, with limited emergency contacts and delayed responses to non-attendance, revealing a need for wider adoption …	London London Inner (North)	Department for Education	1/1
12 Apr 2017	Jamie Fairclough 2017-0119 · Chris Morris Excessively high caseloads for Care Co-ordinators, often exceeding 75-80 service-users, compromised the quality of patient care and staff's ability to manage their …	South East Central and South East Kent	Kent and Medway NHS Trust	0/1
10 Apr 2017	Christiana Pelle 2017-0118 · Heather Williams QC The report identifies a lack of clear guidance for nurses on when to involve a patient’s GP, the absence of a system …	London London Inner (North)	East London NHS Trust Homerton University NHS Trust	0/2
6 Apr 2017	Steven Amos 2017-0117 · Katy Skerrett Concerns exist regarding the appropriate escalation of care for patients experiencing acute deterioration during night shifts over weekend periods.	South West Gloucestershire	Gloucestershire Hospitals NHS Foundation Trust	0/1
6 Apr 2017	John Haughey 2017-0116 · Paul Marks The widespread availability of alcohol-based hand washing gels poses a risk of consumption by confused patients, and there's inadequate dissemination of this …	Yorkshire and the Humber East Riding and Kingston -upon-Hull	NHS England	0/1
10 Apr 2017	John Higgs 2017-0113 · Sarah Slater The system for communicating unexpected, non-cancerous radiological findings is flawed, relying solely on one doctor to notice and input information, with no …	Yorkshire and the Humber South Yorkshire (West)	Department of Health and Social …	1/1
6 Apr 2017	Isabel Gentry 2017-0111 · Maria Voison The deceased's death from meningitis B could have been prevented by vaccination, highlighting an ongoing risk if the teenage group, which is …	South West Avon	Committee of Vaccination and Immunisation Department of Health and Social … John Ratcliffe Hospital Oxford University	0/4
27 Mar 2017	Michael Brennan 2017-0114 · R Brittain A critical backup plan for emergency patient transfer failed due to unavailability of a satellite hospital bed, highlighting a lack of real-time …	London London Inner (North)	University College London Hospitals NHS …	1/1
7 Apr 2017	Christina Witney 2017-0112 · Ian Singleton Concerns include inaccurate patient record keeping, delayed patient reviews despite deteriorating conditions, outdated sepsis guidelines, and insufficient training for locum and temporary …	South West Wiltshire and Swindon	Great Western Hospitals NHS Trust NHS England	0/2
13 Mar 2017	George Dicker 2017-0083 · Andrew Walker There is no alarm or warning system to alert railway signallers when a person accesses the tracks via a gate at the …	London London (North)	RSSB	0/1
7 Apr 2017	Theresa Thompson 2017-0110 · Elizabeth Carlyon A post-splenectomy patient died from Streptococcus pneumonia due to lack of lifelong antibiotic prophylaxis and vaccination. Mixed messages about antibiotic use may …	South West Cornwall and Isle of Scilly	UK Health Security Agency	0/1