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 241 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
2 Nov 2016	William Marson 2016-0394 · Ian Singleton Staff were inadequately trained in ventilator use, unaware of the manual's location, and the provided extracts lacked crucial information for fault recognition …	South West Wiltshire and Swindon	Avon Care Home Limited	1/1
2 Nov 2016	Ivy Morris 2016-0393 · John Ellery Foetal heart rate was not monitored, midwifery guidelines for CTG assessment and obstetric review were not followed, and a midwife lacked recent …	West Midlands Shropshire, Telford and Wrekin	Shrewsbury and Telford NHS Trust	0/1
1 Nov 2016	Trevor Hunking 2016-0391 · Andrew Cox A shortage of Cardiac Intensive Unit Specialist Nurses puts post-operative patients at risk.	South West Plymouth Torbay and South Devon	Health Education England	1/1
31 Oct 2016	Anthony McManus 2016-0388 · Thomas Osborne The system of patient observations was flawed, with nurses performing non-random, fixed-time checks, some observations not conducted, and charts completed retrospectively.	South East Milton Keynes	Priory Group	0/1
31 Oct 2016	Frederick Squires 2016-0389 · Thomas Osborne A lack of clear clinical guidance on when to reintroduce Warfarin after a head injury risks either premature commencement leading to bleeding, …	South East Milton Keynes	N.I.C.E	1/1
31 Oct 2016	James Flynn 2016-0390 · Thomas Osborne Inadequate planning led to a very unwell, elderly diabetic patient being discharged late at night without a detailed care plan, family notification, …	South East Milton Keynes	Oxford University Hospital	0/1
28 Oct 2016	Barbara Turner 2016-0386 · Robert Hunter The Trust's resuscitation policy has overly broad call-out criteria, risking critically ill patients being denied care. Patient transfer protocols were dangerous due …	East Midlands Derby and Derbyshire	Derby Teaching Hospitals NHS Trust	0/1
28 Oct 2016	Alfred Grimshaw 2016-0387 · Michael Singleton A critical hip fracture was missed during initial assessment and an X-ray report. Pre-discharge physiotherapy and occupational therapy reviews were documented but …	North West Blackburn, Hyndham and Ribble Valley	East Lancashire Healthcare NHS Trust	1/1
27 Oct 2016	Samuel Carroll 2016-0384 · Jon Heath Police and ambulance services failed to obtain consent to inform family or friends about a patient's suicidal ideation and hospital attendance, leaving …	Yorkshire and the Humber North Yorkshire (West)	Armstrong Luty Solicitors North Yorkshire Police Yorkshire Ambulance Service NHS Trust	2/3
26 Oct 2016	Alfie Rose 2016-0382 · Louise Hunt Poor inter-hospital communication and ineffective information sharing systems led to missed opportunities for patient transfer and treatment. Clinicians require better education on …	West Midlands Birmingham and Solihull	Dudley Group of Hospitals NHS … University Hospitals Birmingham NHS Trust	2/2
25 Oct 2016	Jane Reason 2016-0376 · Louise Hunt There is a critical shortage of public access defibrillators in colleges and schools, and a need for increased public education on their …	West Midlands Birmingham and Solihull	British Heart Foundation Department for Education Department of Health and Social … NHS England	4/6
25 Oct 2016	Nihad Ousta 2016-0378 · Chinyere Inyama There is a critical absence of written protocols or guidance for head injury management, specifically regarding the frequency and range of necessary …	London London (West)	West London Mental Health Trust	0/1
25 Oct 2016	Ivy Atkin 2016-0379 · Stephanie Haskey A regulatory loophole allows individuals with criminal convictions to become "Nominated Individuals" for care homes without independent suitability assessment, particularly in small, …	East Midlands Nottinghamshire	Care Quality Commission Department of Health and Social … The Secretary of State for …	2/3
25 Oct 2016	Kevin Hefferman 2016-0381 · Graham Danbury Persistent standing water and water flow across a specific carriageway section contributed to numerous past collisions, posing an ongoing danger to road …	East of England Hertfordshire	Highways England	1/1
25 Oct 2016	Matthew Llewellyn-Jones 2016-0385 · Lydia Brown Ward security remains compromised by breached "locked doors" and predictable patient observations, deviating from best practice. The note-recording system lacks mandatory fields …	South West Exeter and Greater Devon	Devon Partnership Trust	1/1
24 Oct 2016	Michelle Barnes Andrew Tweddle Prison officers failed to initiate an ACCT process for a highly distressed prisoner, opting for a vague "offer support" note without a …	North East County Durham and Darlington	NOMS, Prison Service, Equality Rights …	0/1
24 Oct 2016	Margaret Dempsie 2016-0374 · Dianne Hocking Hospital discharge letters contained significant inaccuracies and omissions, often completed by junior doctors who hadn't seen the patient, risking serious care mistakes …	East Midlands Leicester City and Leicestershire South	NHS England University Hospitals of Leicester NHS …	3/2
24 Oct 2016	Hunter Macmillan 2016-0375 · Chinyere Inyama Emergency Department staffing levels were inadequate, preventing the implementation of national and local policies for the timely and effective treatment of suspected …	London London (West)	Chelsea and Westminster Hospitals NHS …	0/1
24 Oct 2016	Joan Green 2016-0383 · Paul Smith The junction design is "challenging" and dangerous, evidenced by a history of fatal collisions and observed "near misses." There were also significant …	East Midlands Lincolnshire (Central)	Lincolnshire County Council	1/1
20 Oct 2016	Victoria Halliday 2016-0370 · Lydia Brown A lack of local female psychiatric intensive care beds, ineffective community psychiatric nursing, and inadequate community support for complex patients left individuals …	East Midlands Leicester City and Leicestershire South	Leicestershire Partnership NHS Trust East Leicestershire & Rutland CCG Secretary of State for Health	3/3