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 235 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
29 Nov 2016	Doris Clarkson 2016-0423 · Andrew Tweddle After a bed pressure sensor was removed, a floor pressure mat was not immediately used as a substitute for a patient with …	North East County Durham and Darlington	Lambton Care Home	1/1
14 Oct 2016	Peter Keep 2016-0362 · Karen Henderson The hospital lacked a clear sedation policy for cardiac procedures, leading to inconsistent drug use, inadequate staff training on anxiolytics, and no …	South East Surrey	Frimley Park Hospital	1/1
13 Oct 2016	Robert Davidson 2016-0363 · Louise Hunt Care home staff lacked basic emergency training, including 999 procedures and CPR. Health Care Assistants had insufficient experience, and vital patient information …	West Midlands Birmingham and Solihull	Aran Court Care Centre Care Quality Commission Department of Health and Social … Jubilee Gardens Care Centre	5/5
13 Oct 2016	Roy Hoey 2016-0360 · Andre Rebello Concerns arose from staff confusion regarding the interpretation and application of safer custody guidance, specifically when to open an ACCT plan, requiring …	North West Liverpool and Wirral	National Offender Management Service	1/1
13 Oct 2016	Philip Evanson 2016-0359 · Alan Moore Road markings on the A49 Tarporley Road, specifically the ghost island, lane dividers, and right turn arrows, are significantly worn and indistinct, …	North West Cheshire	Cheshire Council, Vale Royal Area …	0/1
13 Sep 2016	Arthur Adley 2016-0358 · Andrew Walker Safeguarding systems in care homes were inadequate to prevent a resident who posed a risk to others from causing harm.	London London (North)	Department of Health and Social …	1/1
13 Sep 2016	Lauris Kodors 2016-0357 · Andrew Walker The RSSB Rule Book inadequately permits stopping trains only when a person threatens damage to the train, not when a person is …	London London (North)	RSSB	0/1
12 Oct 2016	Wayne Cornlouer 2016-0356 · Brendan Allen An emergency coding system for medical emergencies was not initially in Night Orders, raising concerns if all staff are now aware of …	South West Dorset	HMP Portland	1/1
11 Oct 2016	Tyrone Lock 2016-0355 · John Ellery Police failed to classify a vulnerable person exhibiting clear distress as such, treating him as an absconding suspect. This led to a …	West Midlands Shropshire, Telford and Wrekin	National Police Air Service West Mercia Police	2/2
11 Oct 2016	Barry Thompson 2016-0354 · Clare Doherty The patient's high-priority triage was not followed by timely review by a doctor or antibiotic administration per national standards, the NEWS score …	North West Blackpool and Fylde	Blackpool Teaching Hospital NHS Trust	0/1
27 Nov 2016	Matthew Russell 2016-0430 · Richard Travers Prison healthcare exhibited failures in medication monitoring, care planning, appointment follow-up, risk flagging, and staff training for ACCT procedures and inter-professional communication.	South East Surrey	Central and North West London … HMP High Down Ministry of Justice	1/3
23 Nov 2016	Flavio Pizarro 2016-0419 · Julie Robertson Lack of warning signs about swimming dangers and absence of safety aids at canal locks, despite previous assurances, creating ongoing risks for …	North West Manchester (North)	Canal and River Trust	0/1
8 Dec 2016	Sandra Brotherton 2016-0400 · Joanne Kearsley A sole carer did not have a contingency plan in place for emergencies, a personal assistant's care plan was not clearly documented …	North West Manchester (South)	Pennine Care NHS Trust	1/1
6 Feb 2017	Nuala Seddon 2017-0034 · R Brittain The patient transfer decision may have been made by non-clinical staff and lacked documentation. Inadequate patient monitoring post-ITU discharge and a failure …	London London Inner (North)	Barts Health NHS Trust University College Hospital NHS Trust	0/2
8 Feb 2017	Anna Phillips 2017-0033 · Andrew Cox The deceased obtained a dangerous, unlicensed weight loss drug (2,4 Dinitrophenol) online, which is known to cause fatalities.	South West Cornwall and Isles of Scilly	Home Office	1/1
9 Feb 2017	Warren Myers 2017-0032 · Andrew Tweddle Inadequate warning signage on the approach to the corner significantly contributed to the accident risk.	North East County Durham and Darlington	Highways Department, County Durham Council	1/1
8 Feb 2017	David Read 2017-0031 · Jacqueline Lake After an initial urgent referral and a cancelled appointment, a new appointment for mental health services was scheduled after a delay of …	East of England Norfolk	Norfolk and Suffolk NHS Trust	1/1
6 Feb 2017	Natalie Thornton 2017-0030 · Simon Nelson Inadequate monitoring and analysis of blood sugar data from insulin pumps, coupled with a lack of formal pump agreements and variable national …	North West Manchester North	Department of Health and Social … Salford Royal NHS Trust	1/2
10 Feb 2017	Raymond Edwards 2017-0029 · Nicola Jones A critical lack of a reliable system for disseminating histology results to named consultants meant crucial diagnostic information was not promptly reviewed, …	Wales North Wales (Eastern and Central)	Betsi Cadwaladr University Health Board	1/1
9 Feb 2017	Matthew Roberts 2017-0028 · Bridget Dolan QC There was no policy to log and scrutinize faxes, leading to potential loss of information, and staff often delayed reading referral details, …	South East West Sussex	Sussex Partnership NHS Trust	1/1