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 232 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
10 Mar 2017	Lester Stacey 2017-0084 · Margaret Jones A patient with complex physical and mental health issues disengaged from community mental health services post-discharge following medication changes, contributing to low …	West Midlands Staffordshire (South)	South Staffordshire and Shropshire NHS …	0/1
9 Mar 2017	Annabel Lewis 2017-0085 · Margaret Jones Mental health services failed to adequately assess risk, record crucial details, or proactively engage with a vulnerable young person and her parents …	West Midlands Staffordshire (South)	Child and Adolescent Mental Health … South Staffordshire and Shropshire NHS …	0/2
23 Mar 2017	Marian Dale 2017-0086 · Alison Mutch The District Nursing Team lacked a central, contemporaneous record-keeping system, storing all notes at the patient's home, and had no protocol for …	North West Manchester (South)	Stockport NHS Trust	0/1
14 Mar 2017	Jack Sheldon 2017-0088 · Nicola Mundy The emergency services lacked an effective system for managing multiple calls, prioritising resources, and mobilising appropriate appliances, compounded by inadequate staff training …	Yorkshire and the Humber South Yorkshire (East)	Chief Fire Officer	0/1
22 Mar 2017	Patricia Donovan 2017-0087 · Philip Spinney Surgery for a neck of femur fracture was delayed beyond NICE guidelines due to theatre staff and resource availability issues, despite the …	Wales South Wales Central	Aneurin Bevan University Health Board	0/1
13 Mar 2017	James O’Brien 2017-0082 · Philip Barlow Critical delays in emergency response, including resuscitation and defibrillator deployment, were compounded by inadequate staff training, poor induction for agency nurses, and …	London London Inner (South)	Cambian Group	1/1
15 Mar 2017	Leah Ratheram 2017-0081 · Louise Hunt Fragmented mental health services for young adults, with separate organizations and incompatible record systems, led to uncoordinated care, poor information sharing, and …	West Midlands Birmingham and Solihull	Birmingham and Solihull Mental Health … Birmingham Children’s Hospital NHS Trust Birmingham City Council Cross City Clinical Commissioning Group	0/5
13 Mar 2017	Daphne Cherry 2017-0080 · Katy Skerrett Concerns exist regarding care home staff's ability to identify and appropriately escalate medical concerns, including when a medical review is needed.	South West Gloucestershire	Care UK	1/1
10 Mar 2017	Anna Walker 2017-0079 · Nadia Persaud Post-operative checks were not compliant with protocol, leading to delayed detection of a bleed, due to failures in portering, ward nurse responsibilities, …	London London (East)	Barking, Havering and Redbridge University …	0/1
16 Mar 2017	Terence White 2017-0078 · Simon Fox The care centre failed to adequately document pressure sore treatment measures, specifically lacking turning charts, which prevented proper monitoring of the condition.	South West Gloucestershire	DAC Beachcroft Claims Ltd Grange Care Centre	1/2
14 Mar 2017	Rebecca Evans 2017-0077 · John Gittins Significant and recurring delays in patient handover at Emergency Departments led to late hospital admission and delayed medical treatment, tying up ambulance …	Wales North Wales (East and Central)	BCUHB HM Stanley Site Welsh Ambulance NHS Trust Ysbyty Gwynedd	1/4
16 Mar 2017	Derek Turnbull 2017-0076-wp25690 · Derek Winter There was an hour-long delay in calling an ambulance for a patient with a head injury and known fall risk, despite clear …	North East Sunderland	Gateshead Health Foundation Trust	0/1
16 Mar 2017	James Mallett 2017-0075 · Yvonne Blake Nursing staff lacked the knowledge and experience to perform neurological observations and respond to serious injuries, leading to delayed medical attention, poor …	East of England Norfolk	Queen Elizabeth Hospital NHS Trust	1/1
16 Mar 2017	Clive Davies 2017-0074 · Andrew Barkley Failures in conducting routine neurological and NEWS observations, including missed checks and an incorrectly calculated score, resulted in the deceased not receiving …	Wales South Wales Central	Cwm Taf Morgannwg University Health … The Chief Coroner Welsh Assembly Government	0/3
15 Mar 2017	Michael Mahon 2017-0073 · Alison Mutch The crucial annual clozapine test was missed, and there was no system in place to identify this omission, allowing symptoms undetectable by …	North West Manchester (South)	Pennine Care NHS Foundation Trust	0/1
20 Mar 2017	James Spencer 2017-0072 · Lydia Brown Inadequate training for induction support officers regarding drug-related collapse and the heightened risks for recently released prisoners due to decreased drug tolerance.	South West Exeter and Greater Devon	Stoneham Bass	1/1
17 Mar 2017	Stephen McDermott 2017-0071 · Claire Hammond Fragmented electronic record systems and poor record usage led to incomplete mental health assessments, missing critical patient history and suicide risk factors …	North West Preston and West Lancashire	Lancashire Care Foundation Trust	0/1
13 Mar 2017	Andrew Lownes 2017-0070 · Kevin McLoughlin The absence of clear, written unloading instructions for heavy, unstable industrial units led to confusion regarding complex banding, creating a risk of …	London London Inner (West)	Glass and Glazing Federation	0/1
20 Mar 2017	Scott Hooper 2017-0068 · David Horsley Incorrect patient weight recording led to inaccurate anticoagulant dosage, and critical clinical decisions were unrecorded. Lessons from internal meetings were not effectively …	South East Portsmouth and South East Hampshire	Southampton General Hospital	0/1
22 Mar 2017	Michael Uriely 2017-0069 · Shirley Radcliffe Inadequate chronic asthma management, lack of coordinated care, and poor inter-service communication led to a failure to follow guidelines and recognise deteriorating …	London London Inner (West)	National Institute for Health and … NHS England Health Education England	2/3