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 233 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
10 Mar 2017	Carol Harvey 2017-0059 · John Gittens There is no procedure to confirm district nurse referral receipt and action, and significant delays exist in developing and implementing a safe …	Wales North Wales (East and Central)	Betsi Cadwaladr University Health Board Ysbyty Gwynedd	1/2
28 Oct 2016	Leslie Lerner 2016-0487 · Veronica Hamilton-Deeley Inadequate junior doctor training in sling application, lack of senior doctor review for high-risk patients, and failure to follow hospital discharge protocols …	South East Brighton and Hove	Brighton and Sussex University Hospitals …	0/1
18 Oct 2016	Isaac Brocklehurst 2016-0486 · Martin Fleming There is a concern about the safety of pedestrian gaps in a low perimeter wall within a communal grassed area, requiring review …	Yorkshire and the Humber West Yorkshire (West)	Incommunities the Local Authority	1/2
24 Jun 2016	Beverley Devanney 2016-0485 · Martin Fleming Police officers lacked formal training for handling complex situations like Miss Devanney's, raising concerns about appropriate responses in similar future circumstances.	Yorkshire and the Humber West Yorkshire (West)	West Yorkshire Police	0/1
13 Jun 2016	Andrew Peebles 2016-0484 · J Adeley Significant failures by RMNs included inadequate documentation of mental health assessments, insufficient review of critical patient information, and a lack of follow-up …	North West Preston and West Lancashire	Lancashire Care NHS Trust	0/1
9 Mar 2017	Frederick Bevan 2017-0060 · Emma Brown A poor handover practice led to paramedics receiving an inaccurate incident history from a non-witnessing nurse instead of the witnessing carer, risking …	West Midlands Birmingham and Solihull	Bondcare Limited	0/1
9 Mar 2017	Billy Wilson 2017-0061 · David Hinchliff Critical gaps exist in mandatory and assessed training for CTG tracing interpretation for both student and practicing midwives, leading to proficiency issues …	Yorkshire and the Humber West Yorkshire (East)	Nursing and Midwifery Council	1/1
8 Mar 2017	Valdas Jasiunas 2017-0062 · Nadia Persaud Custody risk assessments inadequately screen for alcohol dependency, and the computer system's design leads to frequent errors, further complicated by a lack …	London London (East)	Metropolitan Police Service	0/1
8 Mar 2017	Kathleen Cooper 2017-0063 · Lisa Hashmi A medical practitioner raised concerns regarding the difficulties faced by clinicians in different sites of an acute NHS Trust, with errors and …	North West Manchester City	Department of Health Pennine Acute Hospitals NHS Trust	0/2
6 Mar 2017	John Atkin 2017-0064 · Anna Crawford There is a critical breakdown in communication regarding hazard assessment at service-user homes, with occupational therapists unaware of their role in informing …	South East Surrey	Millbrook Healthcare Limited	0/1
13 Sep 2016	Keith Ruston 2016-0483 · Martin Fleming The provided text details the inquest's procedural information and cause of death, but does not include any specific coroner's concerns for future …	Yorkshire and the Humber West Yorkshire (West)	West Yorkshire Ambulance Service NHS … Department of Health and Social …	0/2
6 Oct 2016	Helen Millard 2016-0482 · Paul Marks The "traffic light" ligature risk classification system in psychiatric facilities is flawed; all ligature points, regardless of height, pose an extreme risk …	Yorkshire and the Humber East Riding and Kingston-upon-Hull	NHS England	0/1
3 Mar 2017	Vadims Aleksejevs 2017-0065 · Hassan Shah There is a lack of clarity on whether adult social care or addiction services provide outreach to vulnerable homeless individuals on campsites, …	East Midlands Northamptonshire	Northampton Borough Council Northampton County Council	1/2
8 Feb 2017	Rebecca Shaw 2017-0067 · Martin Fleming The road layout at the junction was unsafe, with obstructed views of oncoming traffic and an inadequate central reservation, increasing the risk …	Yorkshire and the Humber West Yorkshire (West)	Phuket Highway District	0/1
13 Dec 2016	Simon Turvey 2016-0480 · Thomas Osborne The prison failed to inform family members how to report welfare concerns, potentially leading to missed suicide risk factors for detainees.	South East Milton Keynes	HM Prison and Probation Service Prison and Probation Ombudsman	0/2
16 Feb 2017	Etheline De-Gale 2017-0058 · Ian Pears Vague care plans and inadequate staff training on risk assessment led to carers misinterpreting assistance needs. Insufficient staffing levels also compromised resident …	East of England Bedfordshire and Luton	Ambassador House Care Home	1/1
16 Feb 2017	Thomas Green 2017-0057 · Joanne Kearsley A referral to Adult General Psychiatry for an inpatient was not considered or actioned, resulting in no psychiatric follow-up or treatment plan …	North West Manchester (South)	Churchgate Surgery Pennine Care NHS Trust Tameside and Glossop Clinical Commissioning …	1/3
17 Feb 2017	Dean Saunders 2017-0056 · Caroline Beasley-Murray Serious systemic issues include a rigid protocol preventing mentally disordered individuals' transfer from police custody, unclear hospital transfer processes, and inadequate staff …	East of England Essex	Care UK Clinical Services HM Prison and Probation Service NHS England South Essex Partnership Trust	3/4
9 Feb 2017	Rachel Morgan 2017-0055 · Anna Morris The mental health ward failed to review medication despite patient concerns and did not conduct full risk assessments after self-harm incidents. There …	North West Manchester (South)	Greater Manchester West Mental Health …	0/1
22 Feb 2017	Maxim Karpovich 2017-0054 · David Hinchliff Midwives and a junior obstetrician did not understand that the CTG trace was abnormal, and an obstetric registrar incorrectly classified the CTG …	Yorkshire and the Humber West Yorkshire (East)	Royal College of Midwives Royal College of Obstetricians and …	2/2