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 244 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
26 Aug 2016	Pamela Conway 2016-0309 · John Gittins Persistent and unacceptable delays in patient offloading from ambulances at hospitals continue to render ambulance resources unavailable for other calls, creating ongoing …	Wales North Wales (East and Central)	Betsi Cadwaladr University Health Board Welsh Ambulance Service NHS Trust	2/2
26 Aug 2016	Raymond Woodward 2016-wp25391 · Emma Brown The risk of adverse cardiovascular reactions to Buscopan, especially in patients with ischaemic heart disease, is not widely known, and the Summary …	West Midlands Birmingham and Solihull	Medicines and Healthcare Products Regulatory …	2/1
24 Aug 2016	Joyce Ravenhill 2016-wp25389 · Nicholas Rheinberg A lack of operational policy prevented effective communication of an urgent doctor's appointment need between triage nurses, relying instead on automated electronic …	North West Cheshire	North West Ambulance Service NHS …	1/1
23 Aug 2016	Stephen Cahill 2016-0304 · Ian Pears Easy access to the railway line through inadequate fencing and an access gate poses a risk, and a recommended review of these …	East of England Bedfordshire and Luton	Network Rail	1/1
23 Aug 2016	Michael Dundon 2016-0305 · David Hinchliff Unsupervised liquid-absorbing crystals, mistaken for consumables, caused a patient's death. The risks of these sachets are not fully understood, necessitating improved risk …	Yorkshire and the Humber West Yorkshire (East)	Department of Health and Social …	1/1
22 Aug 2016	Nicholas Sullivan 2016-wp25385 · Nigel Meadows Reception staff in the Emergency Department did not use a checklist to identify mental disorder/conditions and record important background issues, there was …	North West Manchester City	Manchester Mental Health and Social … North Manchester General Hospital	0/2
19 Aug 2016	Nathan Lowe 2016-wp25387 · Roy Palmer Consideration should be given to whether more could have been done to contact the patient, given the nature of his illness and …	London City of London	Hertfordshire Partnership University NHS Foundation …	1/1
19 Aug 2016	John Jones 2016-wp25383 · ME Hassell The hospital failed to ensure an unwell patient engaged with crucial group therapy, despite it being the reason for admission, leading to …	London London Inner (North)	Consultant Psychiatrist, Keats House, London Nightingale Hospital	1/2
19 Aug 2016	Amanda Coppen 2016-wp25382 · Philip Barlow The layout of Pilot Busway and the neighbouring road (West Parkside) is unusual and could mislead road users, and a new school …	London London Inner (South)	Lands, Estates and Property Housing … Royal Borough of Greenwich Surface Transport, Transport for London	1/3
19 Aug 2016	Margaret Richardson 2016-wp25380 · Caroline Beasley-Murray A robust, comprehensive Action Plan with timescales needs to be put in place, following the findings of the Serious Incident Investigation and …	East of England Essex	North Essex Mental Health Partnership …	0/1
19 Aug 2016	George Watson 2016-wp25378 · R Brittain Concerns include an unsatisfactory discharge process with unclear medication protocols, inefficient staffing allocation, inadequate monitoring of night shift staff, and insufficient clarity …	West Midlands Coventry	University Hospital, Coventry University Hospitals Coventry and Warwickshire …	0/2
18 Aug 2016	Diana Ritchie 2016-wp25376 · Veronica Hamilton-Deeley Mrs Ritchie was recovering from major surgery and on her second day post operatively was suspected of having an Ileus.	South East Brighton and Hove	Brighton and Sussex University Hospitals …	1/1
17 Aug 2016	Jonathan Sellman 2016-0395 · Peter Dorries Water pooling on a busy road and verges that could propel cars over safety barriers create hazardous driving conditions, despite the drainage …	Yorkshire and the Humber South Yorkshire (West)	Rotherham Borough Council	1/1
16 Aug 2016	Harry Glibbery 2016-wp25368 · Andrew Cox The doctor did not prescribe Clexane in accordance with Derriford Protocol, this was not identified during Pharmacy reviews, and there were difficulties …	South West Plymouth Torbay and South Devon	Plymouth Hospitals NHS Trust	1/1
15 Aug 2016	Micael McMonigle 2016-0289 · Crispin Oliver Staff showed a lack of knowledge and failure to follow policy regarding leave for informal patients, risk assessments were not updated, and …	North East County Durham and Darlington	Tees, Esk and Wear Valley …	0/1
15 Aug 2016	Oliver Ford 2016-0306 · Maria Voisin The telephone triage process lacked a robust risk assessment, and any assessments were often undocumented. Insufficient PCLS weekend cover led to crucial …	South West Avon	Avon and Wiltshire NHS Trust	1/1
n/a	Darren Mindham 2016-wp25374 · Selena Lynch The report identifies that pentobarbital, a drug commonly used in suicides, is not subject to strict controls despite evidence showing that reduced …	London London (South)	Advisory Council on the Misuse …	0/1
15 Aug 2016	Saleh Al-Awlaki 2016-wp25366 · Ian Arrow Please review the suitability of pedestrian railing between the Railway Station and Bus Station at Paignton to reduce the effect of vehicular …	South West Plymouth, Torbay and South Devon	Highways Department, Torbay Council	1/1
12 Aug 2016	Michael Blow 2016-wp25367 · Karen Harrold An INR test was not carried out, and warfarin was restarted based on an outdated INR reading, without considering the impact of …	South East Portsmouth and South East Hampshire	Portsmouth Hospitals NHS Trust	0/1
12 Aug 2016	Jean Stockley 2016-wp25360 · Karen Harrold Despite a deteriorating respiratory condition and a rising NEWS score, a junior doctor did not review the patient, and it was unclear …	South East West Sussex	Royal Sussex County Hospital	1/1