Warren Myers
AI-generated concerns summaryThe coroner noted that warning signage on the approach to a particular corner was inadequate.
Addressed to: Highways Department, County Durham Council
Source · Prevention of Future Deaths
Prevention of Future Deaths Reports
Browse 6,488 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
David Read
AI-generated concerns summaryThe coroner identified significant delays in Mr. Read's access to the Community Mental Health Team, noting that a re-referral after a cancelled appointment resulted in a waiting time exceeding 16 weeks.
Addressed to: Norfolk and Suffolk NHS Trust
Natalie Thornton
AI-generated concerns summaryThe coroner noted inadequate monitoring and trend analysis of blood sugar levels from an insulin pump, and the absence of a formal Pump Agreement. Concerns were also raised regarding variable national support for insulin pump users.
Addressed to: Department of Health and Social Care; Salford Royal NHS Trust
Raymond Edwards
AI-generated concerns summaryThe coroner noted a lack of a reliable system or protocol for disseminating histology results to the named consultant, especially after patient discharge. This could lead to delays in diagnosis and treatment of serious conditions.
Addressed to: Betsi Cadwaladr University Health Board
Matthew Roberts
AI-generated concerns summaryThe coroner identified an absence of policies for logging and scrutinising faxed referrals, and for the EI team to read all information before initial risk assessment. This meant patient needs were not fully understood, and an organizational review of the death was delayed.
Addressed to: Sussex Partnership NHS Trust
Roger Tombs
AI-generated concerns summaryThe coroner raised concerns that placing fall sensor mats on top of crash mats at Sunrise of Knowle may reduce their effectiveness, potentially failing to alert staff when vulnerable residents mobilise and increasing the risk of falls and injury.
Addressed to: Care Quality Commission; Solihull Falls Team; Sunrise Senior Living
Daniel Paylor
AI-generated concerns summaryThe coroner identified insufficient regulatory control, safeguards, and auditing for drugs in secondary employment settings, particularly noting a lack of peer supervision and double authorisation for accessing safes.
Addressed to: Medicine and Health Care Products Regulatory Agency; Home Secretary, Home Office; Member of Parliament for Maidenhead, House of Commons
Peter Usher
AI-generated concerns summaryInadequate detailed assessment of Mr Usher included a failure to obtain information from family, GP, and emergency services. Concerns were also noted regarding non-compliance with Trust policies for Section 136 assessments and medical staffing levels.
Addressed to: North East London NHS Trust
Mark Yafai
AI-generated concerns summaryPolice detention policy lacked clear guidance on assessing detainees who had consumed drugs, leading to broad discretion for custody officers regarding Health Care Professional examination. This ambiguity impacted risk assessment and observation levels.
Addressed to: Office of The Police and Crime Commissioner West Midlands; West Midlands Police
Melanie Lowe
AI-generated concerns summaryThe coroner noted the trust's action plan was very basic, lacked specific detail, and had an absence of supporting evidence, requiring a more rigorous plan.
Addressed to: North Essex University NHS Trust
Ann Hardman
AI-generated concerns summaryThe coroner noted that the current protocol for negative DVT scans at St Mary's Hospital relies on GP re-referral for follow-up, which risks patients not re-attending. An automatic re-attendance system, with GP discretion to cancel, would be preferable.
Addressed to: Isle of Wight NHS Trust
Debrata Sircar
AI-generated concerns summaryThe coroner noted delays in securing a bed and conducting a Mental Health Act assessment for a patient needing hospitalization, due to unavailability of a local authority practitioner. There was an absence of an interim care plan and a lack of clarity regarding psychiatric monitoring during this period.
Addressed to: London Royal Borough of Greenwich; Oxleas NHS Mental Trust
Michelle Lawrence
AI-generated concerns summaryConcerns included the absence of independent investigation into deaths following release from private custody. The coroner also noted insufficient procedures for identifying and managing detainee concealment, inadequate CCTV monitoring, and character limits on the PNC system impacting risk assessment.
Addressed to: DWF LLP; Metropolitan Police; MOJ; Serco
David Knight
AI-generated concerns summaryThe coroner identified a limited risk assessment before S17 leave and a lack of communication with local mental health teams, which meant no mitigation plan was in place. Out-of-county placement also made family involvement difficult.
Addressed to: Department for Health; NHS England
Margaret Wakefield
AI-generated concerns summaryThe coroner noted a lack of timely haemofiltration for a patient with chronic renal disease following a high-risk heart procedure. This potentially life-saving treatment was not available, leading to further deterioration and death, and concerns were raised regarding the need for improved access and contingency planning.
Addressed to: Royal Cornwall Hospital
Liam Day
AI-generated concerns summaryThe coroner noted a lack of preparedness for cold water, including inadequate safety equipment and no means of requesting help. The report highlights the serious risks posed by dangerously low sea temperatures and the rapid onset of hypothermia for those unaware.
Addressed to: British Mountaineering Council; Royal Yachting Association
Christopher MacMorland
AI-generated concerns summaryThe coroner noted concerns that Mr MacMorland was not transferred to a specialist gastroenterology ward despite five consultant requests, potentially affecting his outcome. It was also noted that consultants' requests for patient transfer to specialist wards are commonly not implemented.
Addressed to: Portsmouth Hospitals NHS Trust
Rachal Murphy
AI-generated concerns summaryNo specific concerns were detailed in the provided text for this report.
Addressed to: Medical Centre Stalybridge; Pennine Care Health Foundation NHS Trust; Tameside Council; Tameside General Hospital
Frazer Livesey
AI-generated concerns summaryThe coroner noted that window stays could not be disengaged from the inside in an emergency, which could hinder escape and potentially impact survival or injury severity.
Addressed to: Impact Housing Association
Beryl Farmer
AI-generated concerns summaryThe coroner identified the absence of a falls risk assessment for Mrs Farmer and a lack of justification for her transfer to an unmonitored bay. Concerns were also noted regarding insufficient post-fall observations and the omission of a CT head scan despite significant bruising.
Addressed to: Care Quality Commission-; Sandwell and West Birmingham Hospital NHS Trust