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 237 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
23 Nov 2016	Patrick Steer 2016-0427 · Rachael Griffin Significant communication breakdown and lack of liaison between different specialist medical teams (surgical and coronary care) when providing shared patient care, risking …	North West Manchester (West)	Warrington, Wigan and Leigh NHS …	1/1
18 Jan 2017	Teresa Dennett 2017-0026 · Heidi Connor Absence of a clear pathway for life-saving neurosurgery referral, issues with diagnostic imaging, and insufficient input from stroke physicians were identified as …	East Midlands Nottinghamshire	Derby and Burton Hospitals National Institute for Clinical Excellence NHS England Nottingham University Hospitals NHS Trust	3/5
18 Jan 2017	Michael Parke 2017-0025 · David Roberts Recurring avoidable deaths from misplaced nasogastric tubes revealed staff unaware of or not applying the relevant policy, the trust not ensuring compliance …	North West Cumbria	Department of Health and Social … North Cumbria University NHS Trust: …	2/2
18 Jan 2017	Amanda Coulthard 2017-0024 · David Roberts Recurring avoidable deaths from misplaced nasogastric tubes revealed staff unaware of or not applying the relevant policy, the trust not ensuring compliance …	North West Cumbria	Department of Health and Social … North Cumbria University NHS Trust: …	2/2
25 Jan 2017	Raymond Pollard 2017-0023 · Veronica Hamilton-Deeley A poorly informed decision to discharge a patient with no improvement, without doctor review, led to a failed discharge that seriously compromised …	South East Brighton and Hove	Brighton and Sussex University Hospitals …	1/1
25 Jan 2017	Geraldine Butterfield 2017-0022 · Anna Crawford Nursing staff lacked sufficient knowledge of the choking policy and understanding of when to provide life-sustaining treatment in the presence of a …	South East Surrey	Collingwood Nursing Home	0/1
30 Jan 2017	Margaret Atkinson 2017-0021 · Andrew Tweddle Concerns were raised about the difficulty in describing and assessing risk from unusual prisoner behaviour, potentially leading to its normalisation and overlooking …	North East County Durham and Darlington	G4S National Offender Management Service Tees, Esk and Wear Valley …	1/3
27 Jan 2017	Frances Cappuccini 2017-0020 · Roger Hatch Multiple failures included not checking for retained placenta, ignoring haemorrhage protocols, inadequate anaesthetist supervision, delays in emergency help, and poor note-keeping, all …	South East Kent (North-West)	Maidstone and Tunbridge Wells NHS …	1/1
31 Jan 2017	Dipa Lad 2017-0019 · Heidi Connor The ambulance service deviated from national resuscitation guidance without providing clear staff guidance or training, leading to poor staff awareness of critical …	East Midlands Nottinghamshire	East Midlands Ambulance Service NHS …	1/1
30 Jan 2017	David Holman 2017-0018 · Janet Napier A lack of dedicated cycle lanes on a busy road, coupled with an obstructed footpath and a hazardous kerb dip, created an …	North West Cheshire	Cheshire East Council, Highway Department	1/1
30 Jan 2017	Frederick Chisnall 2017-0017 · Janet Napier Agency staff lacked adequate training in proper documentation, monitoring clinical condition changes, and urgently obtaining medical assistance, raising concerns about patient safety.	North West Cheshire	Halton Clinical Commissioning Group St Helens Clinical Commissioning Group	1/2
27 Jan 2017	Derek Thomas 2017-0016 · Andrew Bradley The unmanned and unprotected railway crossing relies solely on a distant train horn for warning, with previously obscured visibility contributing to safety …	South East Hampshire (North East)	HM Principal Inspector of Railways Office of Rail and Road	0/2
26 Jan 2017	Albie Marlow 2017-0015 · Thomas Osborne A mother's repeated requests for a Caesarean Section were not granted, leading to the baby's death and raising concerns about respecting maternal …	East of England Bedfordshire and Luton	Luton and Dunstable Hospital	1/1
31 Jan 2017	David Griffiths 2017-0013 · Philip Spinney There were no local protocols or specific training for intercostal drain insertion, and recommended real-time ultrasound guidance was unavailable, raising significant safety …	Wales South Wales Central	Cardiff and Vale University Health …	1/1
3 Feb 2017	Gerome Reyes 2017-0012 · Grahame Short There is no confirmation that recommended safety upgrades, such as installing door limit switches on goods lifts, have been implemented, posing a …	South East Southampton and New Forest	Mirage Finance Incorporated Primebulk Shipmanagement Limited	0/2
3 Feb 2017	Robert Entenman 2017-0011 · Henrietta Hill QC Nurses failed to notice an essential humidifier was off, partly due to the machine lacking an alarm. Significant delays occurred in identifying …	London London Inner (South)	Fisher and Paykel HCA Health Care UK London Bridge Hospital Care Quality Commission	3/5
7 Feb 2017	Sheila Bowling 2017-0010 · Christopher Dorries OBE A 'Drive Clean System' in the vehicle, which encourages smooth driving, may have discouraged the driver from making necessary evasive steering movements, …	Yorkshire and the Humber South Yorkshire (West)	First Mainline	1/1
2 Feb 2017	Gordon Arthur 2017-0009 · Rachael Griffin The absence of clear policies for requesting and communicating results of investigative tests to consultants led to critical delays in diagnosing and …	North West Manchester (West)	Salford Royal Hospital	1/1
6 Jan 2017	David Moran 2017-0008 · Nicholas Rheinberg The Trust's referral urgency guidance was imprecise, lacking a default to urgent in cases of doubt or absent screening. Communication between administrative, …	North West Cheshire	5 Boroughs NHS Foundation Trust	1/1
3 Jan 2017	Roseleen O’Donoghue 2017-0007 · Christopher Murray The installed stair lift does not stop in a safe position at the top, leaving the step plate suspended over the stairwell. …	North West Manchester (South)	Your Housing	0/1