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 236 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
13 Feb 2017	Roger Tombs 2017-0027 · Emma Brown Fall sensor mats were improperly placed on crash mats, potentially reducing their effectiveness and increasing the risk of undetected falls, injury, and …	West Midlands Birmingham and Solihull	Care Quality Commission Solihull Falls Team Sunrise Senior Living	2/3
1 Jul 2016	Daniel Paylor 2016-0353 · David Ridley Ambulance services exhibit inadequate regulatory control, safeguards, and auditing for drugs compared to hospitals, lacking sufficient peer supervision and requiring only single-person …	South West Wiltshire and Swindon	Medicine and Health Care Products … Home Secretary, Home Office Member of Parliament for Maidenhead, …	0/3
2 Dec 2016	Peter Usher 2016-0428 · Nadia Persaud Inadequate mental health assessments failed to gather comprehensive patient information from various sources, lacked proper staffing support, and indicated a lack of …	London London (East)	North East London NHS Trust	2/1
9 Nov 2016	Mark Yafai 2016-0403 · Delroy Henry Custody policies use unclear terminology for drug influence, granting officers excessive discretion in risk assessments and leading to inadequate Health Care Professional …	West Midlands Coventry	Office of The Police and … West Midlands Police	0/2
11 Nov 2016	Melanie Lowe 2016-0404 · Caroline Beasley-Murray The Trust's action plan is inadequate, lacking specific detail, supporting evidence, and requiring a far more rigorous approach to prevent future deaths.	East of England Essex	North Essex University NHS Trust	1/1
10 Oct 2016	Ann Hardman 2016-0350 · Caroline Sumeray The DVT scan protocol relies on GP referrals for follow-up, risking patients missing re-scans. An automatic re-booking system from the ultrasound department …	South East Isle of Wight	Isle of Wight NHS Trust	1/1
7 Oct 2016	Debrata Sircar 2016-0352 · Dr Andrew Harris A significant delay in securing a mental health bed and conducting an MHA assessment, coupled with the absence of an interim care …	London London Inner (South)	London Royal Borough of Greenwich Oxleas NHS Mental Trust	1/2
8 Nov 2016	Michelle Lawrence 2016-0412 · Dr Fiona Wilcox Key concerns include lack of independent investigations for deaths after private custody, inadequate concealment questioning, and insufficient strip-search facilities.	London London Inner (West)	DWF LLP Metropolitan Police MOJ Serco	0/4
14 Nov 2016	David Knight 2016-0414 · Emma Carlyon National bed shortages led to out-of-county mental health placement, resulting in inadequate risk assessment for S17 leave, poor communication, and lack of …	South West Cornwall and the Isles of Scilly	Department for Health NHS England	2/2
14 Nov 2016	Margaret Wakefield 2016-0413 · Emma Carlyon Critical care haemofiltration was unavailable in a timely manner, leading to patient deterioration and death, indicating a failure in access and contingency …	South West Cornwall and the Isles of Scilly	Royal Cornwall Hospital	1/1
14 Dec 2016	Liam Day 2016-0402 · Richard Middleton The deceased died of hypothermia after deep water soloing; he was not wearing appropriate safety equipment and the dangers of low temperatures …	South West Dorset	British Mountaineering Council Royal Yachting Association	2/2
16 Nov 2016	Christopher MacMorland 2016-0415 · David Horsley Despite being under the care of gastroenterologists, the patient was not treated in a specialist gastroenterology ward despite multiple requests, and consultant …	South East Portsmouth and South East Hampshire	Portsmouth Hospitals NHS Trust	1/1
8 Dec 2016	Rachal Murphy 2016-0401 · Joanne Kearsley No specific concerns were detailed in the provided text for this report.	North West Manchester (South)	Medical Centre Stalybridge Pennine Care Health Foundation NHS … Tameside Council Tameside General Hospital	2/4
21 Nov 2016	Frazer Livesey 2016-0418 · David Roberts Defective window stays prevented emergency escape from inside, potentially contributing to the deceased's death and a friend's injuries.	North West Cumbria	Impact Housing Association	1/1
24 Nov 2016	Beryl Farmer 2016-0420 · Zafar Siddique A patient at high risk of falls lacked a falls assessment, was moved to an unmonitored bay, and received inadequate post-fall neurological …	West Midlands Black Country	Care Quality Commission- Sandwell and West Birmingham Hospital …	1/2
24 Nov 2016	Timothy Jones 2016-0421 · Louise Hunt GP practice had poor record-keeping, unclear home visit request procedures, misclassified clinical tasks as 'admin', and a policy discouraging home visits for …	West Midlands Birmingham and Solihull	Bright and Hove Clinical Commissioning … Pavillions Richmond Medical Centre Sussex Partnership NHS Trust	1/4
29 Nov 2016	Rex Hall 2016-0422 · Emma Brown Paramedic foundation training was deficient in ECG interpretation and recognising atypical myocardial infarction symptoms, leading to missed diagnoses of serious cardiac conditions.	West Midlands Birmingham and Solihull	Health and Care Professions Council	1/1
30 Nov 2016	Marjorie Bassendine 2016-0424 · Karen Henderson Failure to recognise the cardiac risks of multiple psychotropic medications led to a lack of pre-treatment and regular ECGs to monitor for …	South East Surrey	General Practitioners Medicines and Healthcare products Regulatory … Royal College of Psychiatrists; Department …	2/3
29 Nov 2016	Robert Lloyd 2016-0425 · Emma Carlyon Geographical isolation and reduced transport options severely limited face-to-face alcohol support services, leading to reliance on less effective video links and decreased …	South West Cornwall and Isles of Scilly	Addaction Drug and Alcohol Action Team Cornwall Council St Mary’s Health Centre	2/4
30 Nov 2016	Emma Timbrell 2016-0426 · Geraint Williams Patients with suicidal ideation were given a non-free out-of-hours crisis number, creating a financial barrier to accessing urgent mental health support for …	West Midlands Worcestershire	Worcestershire Health and Care NHS …	0/1