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 234 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
22 Feb 2017	Margaret Jones 2017-0053 · Peter Harrowing Multiple collisions at a junction highlight the need for a reduced speed limit on the A36, improved road signage, and better carriageway …	South West Avon	Avon and Somerset Police National Highways	1/2
20 Feb 2017	Esther Hartsilver 2017-0052 · Sarah Ormond-Walshe The junction's design is inherently dangerous, allowing left-turning vehicles to cross straight-ahead traffic and lacking clear road signage to warn users of …	London London Inner (South)	London Borough of Southwark TFL the police	2/3
22 Feb 2017	Ashley Talbot 2017-0051 · Andrew Barkley Poor design of the school service road and bus bay, coupled with insufficient staff supervision, created a highly dangerous situation for children …	Wales South Wales Central	Bridgend County Borough Council Maesteg Comprehensive School	2/2
17 Feb 2017	Milan Dokic 2017-0050 · Fiona Wilcox The Cycle Superhighway's road surface has reduced grip, creating a significant hazard that increases the likelihood of road users losing control, especially …	London London Inner (West)	TFL	0/1
21 Feb 2017	Jack Portland 2017-0049 · Crispin Butler No specific concerns regarding future deaths were detailed in the provided text, only contact information.	South East Buckinghamshire	Central and North West Hospital … HMP Woodhill Oxford Health NHS Trust	2/3
23 Feb 2017	Grant Burns 2017-0048 · Grahame Short There was a significant lack of cooperative working and communication between mental health and substance misuse services, which impeded a complete root …	South East Southampton and New Forest	Solent NHS Trust	1/1
23 Feb 2017	Luke Mumford 2017-0047 · Kate Thomas The road's narrow, unlit, and unkerbed characteristics, bordered by hedgerows, make the 70 mph speed limit unsafe, with experts stating speeds above …	South East Mid Kent and Medway	Kent County Council	1/1
14 Feb 2017	Wendy Telfer 2017-0046 · Lydia Brown Inadequate training for physical healthcare staff on mental health needs and Mental Health Act application is a concern. A severe national shortage …	South West Exeter and Greater Devon	Devon Partnership NHS Trust NHS Northern, Eastern and Western … Royal Devon and Exeter NHS …	3/3
24 Feb 2017	Doreen Stapleton 2017-0043 · ME Hassell An obsolete email address caused a critical district nursing referral to fail upon discharge, compounded by inadequate, explicit communication to a vulnerable …	London London Inner (North)	Whittington Hospital NHS Trust	1/1
28 Feb 2017	Colin Hodge 2017-0042 · Stephen Nicholls A junction's poor state of repair and lack of clear pavement/roadway boundaries encourage pedestrians to cross unsafely and drivers to cut corners, …	South West Dorset	Dorset Highways Departments	1/1
1 Mar 2017	Ceriann Richards 2017-0041 · Andrew Barkley Significant and prolonged handover delays between ambulance crews and hospital staff led to critical delays in ambulance dispatch and availability, worsening since …	Wales South Wales Central	Neville Hall Hospital Royal Gwent Hospital Welsh Ambulance Service NHS Trust Welsh Government	2/4
28 Feb 2017	Paul Briggs 2017-0040 · Andre Rebello The absence of rumble strips on double white lines at a merging carriageway increases the risk of vehicles inadvertently straying into oncoming …	North West Liverpool and Wirral	Merseyside Passenger Transport Authority	1/1
3 Mar 2017	Alan Walsh 2017-0037 · Andrew Harris A lack of awareness regarding the safety-critical role and vulnerability of ladder spigots poses significant health and safety risks due to potential …	London London Inner (South)	Department for Business and Energy … Health and Safety Executive Youngman	0/3
14 Feb 2017	Derek Lee 2017-0045 · Veronica Hamilton-Deeley No specific concerns regarding future deaths were detailed in the provided text, only contact information.	South East Brighton and Hove	Sussex Partnership NHS Trust	0/1
14 Feb 2017	David Alexander 2017-0044 · Lydia Brown Overturns in the industry are underreported and poorly understood, lacking investigation into causes like hydraulic ram bracket failures. There's inadequate industry guidance …	South West Exeter and Greater Devon	Health and Safety Executive	1/1
1 Mar 2017	Thomas Unsworth 2017-0039 · Jennifer Leeming The junction's design creates a significant "blind spot" for turning drivers, severely limiting their view of pedestrians, raising safety concerns during crossings.	North West Manchester (West)	Bolton Council, Highways Division	1/1
1 Mar 2017	Darran Hunt 2017-0038 · Gareth Lewis The report identifies confusion regarding police training in situations where a detained person puts a harmful substance in their mouth, specifically concerning …	Wales Carmarthenshire and Pembrokeshire	College of Policing National Police Chiefs’ Council	0/2
3 Mar 2017	Joan Rimmer 2017-0036 · Andre Rebello A Community Matron's failure to take physiological readings and incorrectly assess consent for an X-ray in a patient with severe dementia led …	North West Liverpool and Wirral	Care Quality Commission Liverpool Community Health NHS Trust	0/2
2 Mar 2017	Terence Millington 2017-0035 · Christopher Dorries Inadequate arrangements for on-call doctors, including a senior doctor's failure to ensure availability and a consultant's distant location, delayed prompt emergency care …	Yorkshire and the Humber South Yorkshire(West)	Sheffield Hospitals NHS Trust	1/1
25 Oct 2016	Richard Walsh 2016-0377 · Andrew Harris There were failures in communication between custodial and health professionals regarding the deceased's risks and needs, with crucial information being lost as …	London London Inner (South)	DAC Beachcroft LLP Department of Health and Social … Hampshire County Council Home Office	4/6