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.
Reports
| Date | Report | Responses identified |
|---|---|---|
| 14 Nov 2016 |
Martyn Watkins
2016-0409 · Dr Peter Harrowing
Concerns highlight a need for thorough review of the Trust's care, and for the CQC to ensure all deficiencies in care and …
|
1/2 |
| 9 Nov 2016 |
Simon Harper
2016-0410 · Sarah Slater
Insufficient and undocumented training for nurses on portable oxygen cylinder use, following task reassignment, resulted in a critical error during patient transfer.
|
0/1 |
| 7 Nov 2016 |
Maurice Isaacs
2016-0411 · Andrew Barkley
Inadequate falls risk assessment, inconsistent 1:1 supervision, understaffing, and untrained staff performing neurological observations contributed to multiple falls and missed assessments.
|
1/2 |
| 17 Nov 2016 |
Brian Mills
2016-0416 · Geoffrey Sullivan
Consistently high levels of outstanding emergency calls and excessively long waiting times, far exceeding target response times, pose a significant risk.
|
1/1 |
| 2 Feb 2017 |
James Fox
2017-0014 · Andrew Walker
Concerns were raised about the accuracy of close-range police firearms, lack of less-lethal options, inadequate contingency planning for volatile situations, and inconsistent …
|
1/1 |
| 16 Jan 2017 |
Shane Hardy
Katy Skerrett
Individuals with co-occurring addictions and mental health issues fell through service gaps, receiving no assistance. Additionally, there was a lack of inter-agency …
|
0/2 |
| 30 Dec 2016 |
Raymond Shepherd
2016-0467 · Nigel Meadows
Poor record-keeping and unupdated customer files led to missed care visits and unaddressed patient deterioration. Repeated falls and health concerns went without …
|
1/2 |
| 28 Dec 2016 |
Dorethea Parr
2016-0466 · Emma Carlyon
Lack of notification to family and carers about new equipment prevented training and risk assessments. There were no formal protocols for informing …
|
1/1 |
| 28 Dec 2016 |
Simon Charles
2016-0465 · Emma Carlyon
Concerns exist over insufficient preventative measures at Hells Mouth, a known suicide location, beyond a fence. Suggestions included providing suicide support contact …
|
1/1 |
| 22 Dec 2016 |
Edwina Moses
2016-0462 · Andrew Barkley
A poor system for requesting and securing one-to-one nursing cover led to frequent unavailability and staff confusion. This resulted in inadequate staffing …
|
1/2 |
| 22 Dec 2016 |
Demi Williams
2016-0464 · R Brittain
Despite general risk assessments, no specific consideration was given to the method of self-harm Ms Williams had previously described. This critical oversight …
|
0/1 |
| 22 Dec 2016 |
Thomas Wallace
2016-0463 · Jonathan Heath
The junction has an extremely restricted view of traffic due to its layout and a solid wall. Furthermore, signage is limited and …
|
0/1 |
| 6 Dec 2016 |
Tedros Kahssay
2016-0437 · ME Hassell
Inadequate information transfer to prison healthcare, flawed nurse reception screening lacking objective analysis, and emergency response staff having insufficient understanding of medical …
|
1/3 |
| 2 Dec 2016 |
Joshua Smith
2016-0599 · Tony Brown
Emergency services exhibited delayed and uncoordinated response, difficulty in pinpointing location, and failed to follow joint command protocols (JESIP), contributing to critical …
|
3/4 |
| 21 Nov 2016 |
Denis Plater
Kate Thomas
Incomplete medical records, an agency nurse's failure to correctly apply and escalate patient conditions using the NEWS scoring system, and inadequate monitoring …
|
0/2 |
| 14 Nov 2016 |
Benjamin Wylie
2016-0407 · Peter Bedford
Design flaws in piling rig grease nipples, inadequate warnings, insufficient training, and manual deficiencies pose significant operator safety risks.
|
1/3 |
| 11 Nov 2016 |
Karen Thorne
2016-0408 · Alan Walsh
Severe delays in neuroradiology reporting due to a national radiologist shortage prevent timely diagnosis and treatment, necessitating an increase in training positions.
|
1/1 |
| 10 Nov 2016 |
Daniel Willington
2016 · Jonathan Layton
The lack of mandatory personal flotation device wearing on fishing vessel decks at sea unnecessarily increases the risk of death.
|
1/1 |
| 10 Nov 2016 |
Gareth Willington
2016-wp25435 · Jonathan Layton
The lack of mandatory personal flotation device wearing on fishing vessel decks at sea unnecessarily increases the risk of death.
|
1/1 |
| 2 Nov 2016 |
Michaela Thompson
2016-0392 · David Hinchliff
Multi-disciplinary team meetings were inadequately documented, and critical patient phone calls were not recorded or communicated to relevant mental health staff.
|
1/1 |