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 242 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
20 Oct 2016	Sian Jones 2016-0371 · ME Hassell There is a critical lack of protocol and training for monitoring non-detained individuals in police stations, including guidance on interpreting snoring, the …	London London Inner (North)	New Scotland Yard	0/1
20 Oct 2016	Colin Garth 2016-0372 · John Pollard The report text does not detail specific concerns.	North West Manchester (West)	Bolton NHS Trust	1/1
19 Oct 2016	Benjamin Orrill 2016-0367 · Christina Swann The lack of a regulatory body for advanced nurse practitioners, leading to inconsistent appraisal, revalidation, and potential unsupervised practice, poses a significant …	East Midlands Leicester City and Leicestershire South	NHS England Nursing and Midwifery Council	2/2
18 Oct 2016	John Smith 2016-0366 · Jean Harkin Inadequate discharge risk assessment failed to consider a mobility-impaired, incontinent dementia patient's specific home environment and care needs, contributing to a fall …	North West Manchester (City)	Lord Chancellor Wythenshawe Hospital	0/2
18 Oct 2016	Captain James Bedforth 2016-0368 · Christopher Dorries Inadequate DVT scanning guidelines and poor safety-netting led to missed diagnosis. Delayed assessment in ED, issues with anticoagulation management, and poor note-keeping …	Yorkshire and the Humber South Yorkshire (West)	Barnsley Hospital NHS Trust Department of Health and Social …	1/2
17 Oct 2016	Vinod Kumar 2016-0369 · Zafar Siddique Initial triage over-relied on the patient's fall, leading to delayed recognition of potential infection symptoms, missed observations, and inadequate prolonged assessment before …	West Midlands Black Country	New Cross Hospital	0/1
14 Oct 2016	Brandon Arnold 2016-0365 · Ian Pears Motorcycles frequently use residential pathways at excessive speeds, posing a significant and constant risk of death to pedestrians, especially children and vulnerable …	East of England Bedfordshire and Luton	Luton Borough Council	0/1
12 Oct 2016	Rohid Shergill 2016-0364 · Heidi Connor Lack of clear protocols for NGT feeding parental competence, poor information sharing between trusts, and inadequate training for staff on pH testing …	East Midlands Nottinghamshire	Nottingham University Hospitals NHS Trust Nottinghamshire Healthcare NHS Trust	0/2
11 Oct 2016	Vichal Tonpradit 2016-0380 · Geoffrey Sullivan A raised section of tarmac separating a motorway slip road from the main carriageway caused a motorcyclist to fall, leading to fatal …	East of England Hertfordshire	Highways England	1/1
5 Oct 2016	Colin Wellings 2016-0348 · Andrew Barkley Current legislation exempts older, powerful vehicles from essential safety requirements like helmets or seatbelts, posing significant risks to riders and other road …	Wales South Wales Central	Department for Transport	1/1
4 Oct 2016	Haydn Burton 2016-0346 · G A Short Prison staff failed to implement ACCT plans effectively and observations were inadequate. Confidentiality rules for Listeners were unclear regarding active suicide plans, …	South East Hampshire (Central)	HM Prison Service Samaritans	1/2
3 Oct 2016	Amy El-Keria 2016-0347 · Penelope Schofield Hounslow Social Services misunderstood their ongoing welfare role for a child placed far from home and failed to assess for support, neglecting …	South East East Sussex	Department of Health and Social … Hounslow Borough Council	5/2
23 Sep 2016	Karnel Haughton 2016-0339 · Emma Brown Uncensored online videos promote dangerous 'choking game' activities, yet there is no national guidance for schools or support for parents, risking further …	West Midlands Birmingham and Solihull	Department for Education National Society for the Prevention …	0/2
20 Sep 2016	Liam Lambert 2016-0335 · Lydia Brown ACCT documents were incomplete, not properly utilized, and closed prematurely. Resourcing issues compromised officers' ability to ensure prisoner safety, especially for vulnerable …	East Midlands Leicester City and Leicestershire South	HMP YOI Glen Parva Secretary of State for Justice National Offender Management Service	1/3
19 Sep 2016	Daphne McCorkle 2016-0337 · Henrietta Hill QC A critical gap exists in night-time care provision for patients requiring frequent turning to prevent pressure sores, as neither district nurses nor …	London London Inner (South)	London Borough of Lewisham Adult … NHS Lewisham Clinical Commissioning Group	1/2
19 Sep 2016	Charles Pitcher 2016-0336 · Ian Arrow The bridge barrier is too easy to bypass, leading to multiple suicides, and current safety measures are inadequate compared to other significant …	South West Plymouth, Torbay and South Devon	Cornwall County Council Devon County Council Tamar Bridge & Torpoint Ferry …	0/3
16 Sep 2016	Martha Davies 2016-0331 · Caroline Beasley-Murray Serious communication breakdowns, over-reliance on junior/agency staff, and a lack of prompt response to patient deterioration contributed to significant care failings and …	East of England Essex	Anglian Community Enterprise	0/1
15 Sep 2016	Richard Breatnach 2016-0330 · Veronia Hamilton-Deeley Online medication prescribing allowed applicants to provide false information without verification, leading to excessive and inappropriate prescription of an addictive drug without …	South East Brighton and Hove	H R Healthcare Limited NHS England	1/2
16 Sep 2016	David Phillips 2016-0334 · Colin Phillips An inappropriate healthcare professional conducted the mental health assessment for a vulnerable older person, and the assessing professional lacked critical access to …	Wales Swansea Neath and Port Talbot	Mitie NHS Wales South Wales Police	0/3
16 Sep 2016	Denis Cronin 2016-0332 · Catherine Mason Significant failings in dive training, planning, and risk assessment led to an unqualified diver teaching an inexperienced individual. Important safety information was …	East Midlands Leicester City and South Leicestershire	British Sub Aqua Club Dulwich Dive Club	2/2