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.

Response tracker Organisations Advanced search

Keyword

Browse by year

Browse by region

Sort

Reports

6,383 reports · Page 231 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
7 Apr 2017	Annette Krasinsky-Lloyd 2017-0109 · Darren Stewart Inadequate A&E governance, including an unsupervised SHO and delayed consultant involvement, led to critical delays in patient assessment, test results, anti-coagulation reversal, …	South East Surrey	Royal Surrey County Hospital NHS …	0/1
7 Apr 2017	Raymond Berry 2017-0108 · Anna Loxton The parameters for Supplementary Restraint System (airbag) deployment may be inadequate, failing to activate airbags in collisions where impact is absorbed by …	South East Surrey	Department for Transport Driver and Vehicle Standards Agency Honda UK	0/3
4 Apr 2017	Christina Smith 2017-0107 · Tony Williams Critical communication breakdown led to both the patient and her GP being unaware of a diagnosed thoracic aneurysm, which was also not …	South West Somerset	Bute House Surgery Yeovil District Hospital	0/2
4 Apr 2017	Arthur Morley 2017-0106 · Crispin Butler The report indicated concerns but did not provide specific details on what matters gave rise to them, making it impossible to identify …	South East Buckinghamshire	HMP Grendon	0/1
4 Apr 2017	Kymberley Holden 2017-0105 · Elizabeth Didcock Persistent unsafe prescribing of controlled drugs and inadequate understanding of reporting serious incidents, compounded by poorly coordinated management for neurological patients, pose …	East Midlands Nottinghamshire	Derbyshire Community Health Services Ivy Grove Surgery	0/2
3 Apr 2017	Abigail Baynham 2017-0104 · Zafar Siddique The report notes that when Ms Baynham left hospital, there was no referral made back to the Mental Health Liaison Service which …	West Midlands Black Country	Black Country NHS New Cross Hospital	0/2
4 Apr 2017	Sean Salvin 2017-0103 · Christopher Dorries Inadequate information sharing, inaccurate incident location, and deficient risk assessments for highway hazards (including flooding and tree growth impacting lighting) contributed to …	Yorkshire and the Humber South Yorkshire (West)	Amey PLC Sheffield Council South Yorkshire Police Yorkshire Water PLC	1/4
4 Apr 2017	Robert Owens 2017-0102 · Andrew Barkley Outdated guidelines and failure to follow national guidance for Naso Gastric tube insertion, including PH testing and X-rays, compromised patient safety, compounded …	Wales South Wales Central	CWM Taf University Health Board	0/1
27 Mar 2017	Steven Fone 2017-0101 · Christopher Murray The practice of allowing interchangeable prescription collection by different customers without consent raises concerns about potential abuse, stock-piling, and increased risk of …	North West Manchester (South)	Adams Pharmacy the relevant regulator of pharmacies	0/2
29 Mar 2017	John Jaundoo 2017-0100 · Julie Goulding Probation failed to appropriately place high-risk offenders and maintain dynamic risk assessments, while Adult Social Services lacked oversight, leading to unsuitable placements …	North West Liverpool and Wirral	Liverpool City Council National Offender Management Service	0/2
31 Mar 2017	Malcolm Langford 2017-0099 · Peter Bedford Severely restricted visibility at a road junction, caused by a fence and trees, makes safe exiting impossible for normal drivers, indicating a …	South East Berkshire	Transport Manager, Reading Borough Council	1/1
30 Mar 2017	Ondrej Suha 2017-0098 · Andrew Haigh Prison officers lacked specific training for night shifts and basic resuscitation, hindering their ability to respond effectively to emergencies.	West Midlands Staffordshire (South)	National Offender Management Service	0/1
29 Mar 2017	Lyndsey Holt 2017-0096 · Nicola Mundy Methadone was prescribed unsafely over the phone without a face-to-face consultation, leading to a lack of critical patient information and an inappropriate …	Yorkshire and the Humber South Yorkshire (East)	Dinnington Group Practice Yorkshire Ambulance Service NHS Foundation …	0/2
28 Mar 2017	John Williams 2017-0094 · ME Hassell Inaccuracies in self-harm recording by a reception nurse and a missed second reception screen indicate potential training deficiencies and a need for …	London London Inner (North)	Care UK HMP Pentonville National Offender Management Service NHS England	1/4
29 Mar 2017	Beryl Foster 2017-0095 · David Horsley The practice of posting endoscopy discharge summaries, instead of emailing them, critically delayed GP awareness of medication changes, risking patient safety.	South East Portsmouth and South East Hampshire	Portsmouth Hospitals NHS Trust	0/1
14 Mar 2017	Mariana Pinto 2017-0093 · ME Hassell The emergency department failed to effectively communicate illness progression and crisis team limitations to the family. The crisis line nurse did not …	London London Inner (North)	East London NHS Trust	2/1
23 Mar 2017	Antony Abbott 2017-0092 · Jennifer Leeming Spanish Custody Officers, despite receiving first aid training for detainees, are not trained in Cardio Pulmonary Resuscitation (CPR), posing a risk in …	North West Manchester (West)	Foreign, Commonwealth & Development Office	0/1
28 Mar 2017	Olive Daynes 2017-0091 · Paul Cooper A GP was unaware of hospital advice regarding a patient's medication change and increased INR levels, due to a delay in the …	East Midlands Leicestershire (South)	United Lincolnshire Hospitals NHS Trust	1/1
20 Mar 2017	Ralph Brazier 2017-0090 · Christopher Sutton-Mattocks Insufficient consideration of increasing cyclist numbers on highways leads to inadequate defect categorisation, prioritising cycle lanes over highways where many cyclists also …	South East Surrey	Surrey County Council	1/1
23 Mar 2017	Grant Richards 2017-0089 · Ian Wade QC The GP surgery failed to act on A&E follow-up recommendations and mental health team faxed documents, revealing systemic management control issues and …	London London (East)	Wanstead Place Surgery	0/1