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 238 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
11 Jan 2017	Charles Rendell 2017-0006 · Peter Bedford There is inadequate communication to patients and prescribing clinicians about Ciprofloxacin's rare but serious side effect of suicidal ideation. This lack of …	South East Berkshire	Bayer Plc	2/1
9 Jan 2017	Ana Sirghi-Marin 2017-0005 · ME Hassell A guideline is needed for immediate microbiological analysis of discolored, non-purulent/non-blood-stained amniotic fluid samples. This precaution is vital for early infection detection, …	London London Inner (North)	British Maternal and Fetal Medicine … Royal College of Obstetricians and …	1/2
11 Jan 2017	Emily Voukelatou 2017-0004 · ME Hassell The crisis team routinely failed to involve family in patient care, leading to lost input. Repeated unreturned calls from worried relatives also …	London London Inner (North)	Camden and Islington NHS Trust	1/1
13 Jan 2017	Natalie Gray 2017-0003 · Patricia Harding Concerns included an unfinalized discharge pathway for personality disorder patients, inadequate risk assessment forms and subjective terminology leading to inaccurate assessments. Crucially, …	South East Mid Kent and Medway	Kent and Medway NHS	1/1
13 Jan 2017	Sarah Tyler 2017-0002 · John Gittins Pervasive hospital admission delays due to insufficient beds were exacerbated by increased 'bed blocking' on weekends, stemming from reduced patient discharges. This …	Wales North Wales (East and Central)	Betsi Cadwaladr University Health Board	1/1
12 Jan 2017	Jennifer Clark 2017-0001 · Thomas Osborne The neonatal unit has insufficient beds and is inadequate for the high number of births, despite an expansion proposal being rejected. This …	East of England Bedfordshire and Luton	Watford General Hospital	1/1
24 Oct 2016	Jeff Miles 2016-0406 · Tony Williams Prolonged occupational exposure to white spirit, involving both direct skin contact and vapour inhalation over 13 years, caused the employee's death.	South West Somerset	Amphenol Thermometrics (UK) Ltd	0/1
24 Oct 2016	Sally Eveleigh 2016-0405 · Tony Williams Despite a history of multiple accidents and impending junction improvements, the maximum speed limit for vehicles approaching the hazardous junction was not …	South West Somerset	Taunton Deane District Council	0/1
29 Nov 2016	John Atkinson 2016-0429 · Nicola Mundy The coroner identified a lack of updated risk assessments, failure to identify changes in presentation and risk level, absence of a system …	Yorkshire and the Humber South Yorkshire (East)	Rotherham NHS Trust	1/1
5 Dec 2016	Brian Gerrard 2016-0432 · Nicholas Rheinberg Deficiencies in staff understanding of mental capacity, best interests meeting management, and Deprivation of Liberty Safeguarding procedures led to inaccurate decision-making and …	North West Cheshire	Abbey Court Independent Hospital	0/1
6 Dec 2016	Joyce Crompton 2016-0434 · Rachael Griffin The care home lacked written policies, systematic checklists, and refresher training for Speech and Language Therapy (SALT) referrals, leading to missed assessments …	North West Manchester (West)	CLS Care Services	1/1
7 Oct 2016	Norman Beard 2016-0438 · Margaret Jones Poor management, staff shortages, and lack of policies contributed to neglected pressure ulcers and significant weight loss. Delayed specialist referrals and ignored …	West Midlands Stoke-on-Trent and North Staffordshire	Care First Homes	0/1
8 Dec 2016	Cameron Forster 2016-0436 · Michael Oakley Parachutes were not supplied for a light aircraft flight, and there is no mandatory spin recovery training specific to aircraft types, increasing …	Yorkshire and the Humber North Yorkshire (East)	Department for Transport	0/1
8 Dec 2016	Ajvir Sandhu 2016-0436-wp25562 · Michael Oakley Safety concerns include the lack of mandatory parachutes with static lines in certain aircraft and insufficient mandatory spin recovery training on specific …	Yorkshire and the Humber North Yorkshire (East)	Department for Transport	0/1
5 Dec 2016	Christopher Brennan 2016-0433 · Selena Lynch The adolescent psychiatric unit lacked specific policies for managing self-harm risks from items, and emergency equipment did not include laryngoscopes, despite their …	London London (South)	Resuscitation Council (UK) South London and Maudsley NHS …	0/2
7 Dec 2016	Andrew Machin 2016-0349 · Emma Whitting Limited support was provided to a prison employee during a prolonged disciplinary process, and no internal investigation was conducted into the dismissal …	West Midlands Coventry	National Offender Management Service	0/1
7 Dec 2016	Dominic Travis 2016-0435 · Lisa Hashmi The acute psychiatric ward lacked specialist provision for young adults, and internal investigations into deaths were compromised by a lack of independence …	North West Manchester (North)	Department of Health and Social … Pennine Care NHS Trust	0/2
9 Dec 2016	Shelia Stokes 2016-0439 · Heidi Connor Systemic delays plagued patient care, including following up on missed appointments, acting on alerts, and an inadequate protocol for obtaining custom-made grafts, …	East Midlands Nottinghamshire	Sherwood Forest Hospital Trust	2/1
8 Dec 2016	Mary Muldowney 2016-0440 · ME Hassell Critical delays occurred in transferring a patient for essential neurosurgery due to a lack of intensive care beds, despite the time-sensitive nature …	London London Inner (North)	Brighton and Sussex University Hospitals … Kings College Hospital NHS England St George’s University Hospital	0/4
9 Dec 2016	Roy Lawton 2016-0441 · Andrew Haigh The deceased's dressing gown was highly inflammable regardless of fabric, raising concerns about product safety, the need for flammability warnings, or manufacturing …	West Midlands Staffordshire (South)	Marks and Spencer	1/1