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 243 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
13 Sep 2016	Roy Millar Andrew Cox Ward administrators in the Neurology Department were unaware of their responsibility to book follow-up appointments, leading to a large number of patients, …	South West Plymouth Torbay and South Devon	CQC, Safeguarding team National Customer Service Centre Secretary of State for Health	0/3
13 Sep 2016	Zane Gbangbola 2016-0328 · Richard Travers Inadequate and misleading safety guidance for internal combustion engine equipment used in confined spaces, coupled with the misleading use of the HSE …	South East Surrey	Department for Work and Pensions HAE Ltd Health and Safety Executive	0/3
7 Sep 2016	Glen Jordan 2016-0329 · Zafar Siddique Staff failed to remove a holdall bag with an attached strap, a ligature risk, from a patient's room, highlighting a lapse in …	West Midlands Black Country	Care Quality Commission Dudley and Walsall Mental Health …	1/2
7 Sep 2016	Louise Turner 2016-0322 · Lydia Brown Inadequate post-discharge mental health care, ineffective support systems, and inappropriate expectations for patients to initiate contact were identified. Devon also lacks female …	South West Exeter and Greater Devon	Department of Health and Social … Devon Partnership Trust NHS Northern Eastern and Western …	1/3
7 Sep 2016	Dildar Shariff 2016-0321 · Julie Robertson There is a critical lack of national awareness and NICE guideline inclusion regarding the increased haemorrhage risk in haemodialysis or uremia patients, …	North West Manchester (North)	Department of Health and Social … N.I.C.E Pennine Acute NHS Trust	2/3
7 Sep 2016	Christopher Jones 2016-0319 · John Gittins Inadequate mental health care planning resulted in patients being without consultant review for extended periods post-discharge. Increased demand on services also created …	Wales North Wales (East and Central)	Betsi Cadwaladr University Health Board	1/1
7 Sep 2016	Beverley Upton 2016-0318 · Robert Chapman Unsafe loading shovel work methods and a lack of clear guidance and enforcement for drivers to stay in cabs put workers at …	East Midlands Rutland and North Leicestershire	MAC Skip Hire Limited	0/1
7 Sep 2016	Edward Mallen 2016-0254 · Belinda Cheney A GP prescribed medication based on advice from a non-prescribing nurse without adequately informing the patient about critical side effects or support …	East of England Cambridgeshire and Peterborough	Cambridge and Peterborough NHS Trust Cambridgeshire and Peterborough Clinical Commissioning … GP Practice Orchard Surgery NHS England	0/4
6 Sep 2016	David Wade 2016-0324 · Michael Singleton The provided text is incomplete and does not detail specific concerns.	North West Blackburn, Hyndburn and Ribble Valley	NHS England	1/1
6 Sep 2016	Warren Sampson 2016-0320 · Caroline Beasley-Murray Prison healthcare lacked consistent input in ACCT reviews and a follow-up process for missed screenings. Officers were also not adequately familiar with …	East of England Essex	Care UK Family Solicitors HMP	1/3
6 Sep 2016	Samantha Hopkins 2016-0316 · David Horsley Critical trial exclusions, such as for pregnant women, were overlooked due to insufficient prominence on drug packet warnings and lack of guidance …	South East Portsmouth and South East Hampshire	South Central Ambulance Service Warwick Medical School	2/2
5 Sep 2016	Benjamin Brown 2016-0326 · Andrew Walker Concerns identified inadequate auditing of 15-minute observations and clozapine management, alongside insufficient staff training for patient resuscitation.	London London (North)	Edgware Community Hospital	0/1
5 Sep 2016	John Jones 2016-0327 · Robert Sowersby A significant delay in notifying the GP of patient discharge from the Crisis Team left the patient without community support. Crisis Team …	South West Avon	Avon and Wiltshire Mental Health …	0/1
5 Sep 2016	Imad Hassan 2016-0315 · Graeme Hughes There is no formal backup plan for PCI procedures when primary hospitals lack capacity, and no agreed pathways for accessing critical care …	Wales South Wales Central	Swansea Bay University Health Board Cardiff and Vale University Health … Cwm Taf Morgannwg University Health … Minister for Health & Social …	2/5
2 Sep 2016	Catherine Dinnen 2016-0313 · Nadia Persaud Concerns include significant delays in medical reviews, particularly out-of-hours, due to inadequate medical staffing levels. Lost observation records further hindered investigation into …	London London (East)	Barts Health NHS Trust	0/1
30 Aug 2016	Harry Gill 2016-0323 · Michael Singleton The NHS 111 vomiting pathways were not robust, leading to inappropriate responses in most calls and failing to ensure adequate patient care.	North West Blackburn, Hyndburn and Ribble Valley	NHS England	1/1
30 Aug 2016	Peter Lawrence 2016-0314 · Simon Milburn The initial screening process for new prisoners lacked a robust method to identify and comprehensively record less obvious risk factors, particularly with …	East of England Cambridgeshire and Peterborough	HM Prison and Probation Service	0/1
30 Aug 2016	Robert Dearing 2016-0311 · Paul Smith Unregulated, non-standard anti-glare visors significantly obscured driver vision due to extremely low light transmission. A lack of legislation and British Standard certification …	East Midlands Lincolnshire (Central)	Department for Transport	0/1
26 Aug 2016	Kyles Lowes 2016-0307 · Tony Brown Long emergency care journey times and a single paramedic crew after 10 pm in a busy area create significant risk of delayed …	North East North Northumberland	NEAS NHS Trust NHS Northumberland Clinical Commissioning Group	1/2
26 Aug 2016	Maureen Flynn 2016-0310 · Andrew Bridgman A critical falls risk assessment was not completed, and staff were unaware of this omission due to a lack of system to …	North West Manchester (South)	Stockport NHS Foundation Trust	1/1