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 239 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
15 Dec 2016	Jean McHale 2016-0456 · Thomas Osborne Inadequate treatment of pressure ulcers can lead to severe complications like osteomyelitis and sepsis in the elderly, compounded by an insufficient number …	East of England Bedfordshire and Luton	Luton and Dunstable Hospital South Essex Partnership NHS Trust	1/2
15 Dec 2016	Jane Stables 2016-0457 · Nicola Mundy Ineffective communication between nurses and the general practitioner regarding a patient's ongoing significant pain levels impeded the provision of appropriate care.	Yorkshire and the Humber South Yorkshire (East)	Rotherham, Doncaster and South Humber …	2/1
16 Dec 2016	Lita Serkes 2016-0458 · ME Hassell Multiple clinical failures occurred, including inaccurate medical records, delayed stroke diagnosis, critical delays in patient transfer to specialist care, and unreviewed crucial …	London London Inner (North)	Royal London Hospital	1/1
12 Dec 2016	Ellen Kelly 2016-0451 · Edwin Buckett Residential fire safety is compromised by flat front doors lacking self-closing mechanisms and failing to meet 30-minute fire resistance standards, leading to …	London London Inner (North)	London Borough of Camden	1/1
21 Dec 2016	David Cooper 2016-0459 · Andrew Barkley Critical concerns included inadequate handover for fall risks between wards and poor record-keeping, especially regarding falls documentation. There was also a lack …	Wales South Wales Central	ABMU Health Board Welsh Assembly Government	1/2
22 Dec 2016	Georgina Lewis 2016-0460 · David Bowen Concerns included the lack of family notification or consultation regarding discharge, absence of a discharge plan or follow-up support, and no contemporaneous …	Wales Gwent	Aneurin Bevan University Hospital Board	0/1
12 Oct 2016	Calam Atour 2016-0461 · David Ridley Chronic understaffing in the prison system compromises officer safety and prisoner welfare. The method for determining staffing levels also fails to account …	South West Wiltshire and Swindon	National Offender Management Service	0/1
12 Dec 2016	Carol Leesley 2016-0442 · David Urpeth A safeguarding report made by a GP was not acted upon, despite automated acknowledgment, due to an unknown systemic or IT error, …	Yorkshire and the Humber South Yorkshire (West)	Sheffield City Council	1/1
12 Dec 2016	Dennis Lavington 2016-0443 · Grahame Short The health centre car park design creates a pedestrian safety hazard, particularly for disabled patients, due to the lack of dedicated crossings …	South East Southampton and New Forest	Solent NHS Trust	1/1
15 Dec 2016	Janet Millar 2016-0444 · Nicholas Rheinberg A potential training deficit exists regarding supporting nicotine-addicted and suicidal patients through withdrawal, which could compromise their care in a hospital setting …	North West Cheshire	Bowmere Hospital	0/1
14 Dec 2016	Jaroslaw Rogala 2016-0145 · Dr Fiona Wilcox Patients with addiction are at risk of suicide due to a lack of in-patient facilities for care and supervision during crises.	London London Inner (West)	South West and St George’s … West London Care Commissioning Group	1/2
15 Dec 2016	Pamela Gower 2016-0446 · Andrew Tweddle Concerns remain whether the deceased skydiver was progressed beyond her abilities, questioning the adequacy of training intervals and overall progression for such …	North East County Durham and Darlington	British Parachute Association	1/1
15 Dec 2016	Francis Lea 2016-0447 · Lydia Brown Next of kin were not involved in a significant decision to change the patient's GP, and there was no documented rationale, consent, …	East Midlands Leicester (City and South)	East Leicestershire and Rutland Clinical … Hazelmere Medical Centre Northfield Medical Practice	3/3
16 Dec 2016	Charles Woodward 2016-0449 · Nicholas Rheinberg Inadequate communication between the hospital, GP, and community nurses post-discharge, combined with insufficient patient monitoring and miscommunication with family, led to unappreciated …	North West Cheshire	Cancer Governance Board Mid Cheshire NHS Trust	0/2
15 Dec 2016	Winifred Elliott 2016-0448 · Dr Fiona Wilcox The removal of crucial resident transfer information from display in care homes hinders busy staff, potentially leading to inappropriate transfers and injuries …	London London Inner (West)	Care Quality Commission London Borough of Wan Meadbank Care Home Westminster City Council	1/4
16 Dec 2016	Edwin Flett 2016-0450 · Andrew Harris This beach has an acknowledged high risk of death due to dangerous currents, yet specific warnings for tourists are insufficient, and no …	London London Inner (South)	Foreign, Commonwealth & Development Office	0/1
16 Dec 2016	Exauce Paoulen 2016-0452 · Emma Brown Dangerous road conditions near a park entrance are created by the absence of a pedestrian crossing, vehicles obscuring views, and the speed …	West Midlands Birmingham and Solihull	Highways Department Birmingham City Council	1/1
16 Dec 2016	Mark Lilliott 2016-0453 · Julie Goulding Delays in accessing a radio-equipped senior officer for emergency assistance within the prison, exacerbated by noise on the wing, could critically impede …	North West Liverpool and Wirral	HMP Liverpool	0/1
19 Dec 2016	Terence Hawkins 2016-0454 · Nadia Persaud There was no system for regular medical monitoring of care home residents, with one not seen by a GP for months. Difficulties …	London London (East)	Lime Tree Surgery	1/1
19 Dec 2016	Grace Roseman 2016-0455 · Penelope Schofield Crib manufacturer failed to fully address the risk of death from an un-modified crib design, leaving a large number of potentially unsafe …	South East West Sussex	Bednest Ltd Department for Business, Energy and …	2/2