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 245 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
12 Aug 2016	Stephen St Clair 2016-wp25358 · Caroline Sumeray Prison guidance for suicide risk factors is inadequate, omitting irrational behaviour as a key indicator of psychosis, which led to insufficient monitoring …	South East Isle of Wight	Ministry of Justice HM Prison and Probation Service	0/2
11 Aug 2016	Thomas Gallagher 2016-wp25354 · L Hashmi Staff lacked formal training in risk assessment and child mental health, and there was intentional disregard of force policies; also, decisions not …	Greater Manchester (North)	Greater Manchester Police	1/1
11 Aug 2016	Anthony Preston 2016-wp25351 · Robert Chapman The discharge system lacked robustness, with no documentary proof of a telephone call to the Crisis Team, and no immediate follow-up notification …	East Midlands Rutland and North Leicestershire	Leicestershire Partnership NHS Trust Priory Hospital, Cheadle	0/2
10 Aug 2016	Thomas Jordan David Hinchliff Communication failures between the hospital and prison healthcare resulted in continued administration of a discontinued drug, as discharge information was not promptly …	Yorkshire and the Humber West Yorkshire (East)	Her Majesty's Prison, Leeds The Leeds Teaching Hospitals NHS …	0/2
10 Aug 2016	Thomas Jordan 2016-0287 · David Hinchliff Communication breakdown and failure to review discharge correspondence at the prison led to continued, incorrect drug administration after hospital clinicians requested discontinuation. …	Yorkshire and the Humber Yorkshire West (East)	Head of Healthcare, HMP Leeds Medical Director, Leeds Teaching Hospitals, …	1/2
10 Aug 2016	Kevin Ritson 2016-wp25356 · David Roberts A chevron warning sign was missing following an earlier accident, the road surface was in poor condition with patched holes, and the …	North West Cumbria	Highways Department, Cumbria County Council	0/1
10 Aug 2016	Ben Collins 2016-wp25353 · Simon Wickens Those present at the trench rescue lacked the knowledge to operate the Suction Excavator, and the company only provided one trained person; …	South East Surrey	Digsafe Suction Excavations Limited Health and Safety Executive	1/2
7 Aug 2016	Rohan Fitzsimons 2016-0288 · Peter Harrowing Insufficient inpatient mental health beds, influenced by funding, led to significant delays in Mental Health Act assessments, posing a risk of individuals …	South West Avon	Avon and Wiltshire Mental Health … Bristol Clinical Commissioning Group Care Quality Commission	1/3
4 Aug 2016	Susan Hamlett 2016-wp25372 · Ian Pears The British Transport investigation revealed that the deceased gained access to the railway line through an access gate that provided little deterrence, …	East of England Bedfordshire and Luton	Network Rail	1/1
3 Aug 2016	Winston Harris 2016-wp25349 · Louise Hunt The care plan for Mr Harris did not address his risk of absconding, and hospital staff did not consider an emergency DOLS …	West Midlands Birmingham and Solihull	Birmingham City Council Kerria Court residential home Sandwell and West Birmingham Hospitals …	2/3
1 Aug 2016	Pamela Gressman 2016-wp25347 · Andrew Tweddle There was insufficient consideration of physical effects from reported foreign body ingestion, leading to an absence of a clear treatment and observation …	North East County Durham and Darlington	Tees, Esk and Wear Valley	1/1
1 Aug 2016	Joshua Knox-Hooke 2016-wp25346 · Nadia Persaud The patient was not kept within eyesight at all times as required by Trust policy, and it is common for patients to …	London Greater (East)	North Middlesex University Hospital NHS …	1/1
29 Jul 2016	Miles Abel 2016-wp25345 · Ian Singleton The procedure for GPs to refer patients to the Community Mental Health Team lacked an audit trail to confirm faxes were sent, …	South West Wiltshire and Swindon	Department of Health and Social … Endless Street Surgery	2/2
29 Jul 2016	Danny Sweet 2016-wp25341 · Andrew Cox The coroner questioned whether it was appropriate to presume the best-case scenario for patients presenting inconsistently and whether there should be a …	South West Cornwall and the Isles of Scilly	Cornwall Partnership Foundation Trust	1/1
28 Jul 2016	Leslie Morrison 2016-wp25337 · Nigel Meadows No formal mental capacity assessment or consideration of a DoLS authorisation was undertaken in the community, and details of the patient's mental …	North West Manchester City	Manchester University NHS Foundation Trust Manchester Mental Health and Social … Regard Care	1/3
27 Jul 2016	Cerith Pugh 2016-0271 · Jonathan Layton Referrals to consultants were inappropriately handled by middle-grade doctors, and essential liver function tests were declined due to a rigid demand management …	Wales Carmarthenshire and Pembrokeshire	Hywel Dda University Health Board	1/1
27 Jul 2016	James Hedge 2016-wp25334 · Andrew Barkley Insulin pump guidance inadequately highlights misuse dangers from incorrect cartridge insertion, and patient education fails to emphasize the rapid life-threatening nature of …	Wales South Wales Central	Medicines and Healthcare Products Regulatory … NHS England NHS Wales Roche Diagnostics Limited	4/4
26 Jul 2016	Leslie Matthews 2016-0276 · Crispin Oliver Undetected, damaged, and defective flow meters were available for use on the respiratory ward.	North East County Durham and Darlington	Medicines and Healthcare Products Regulatory … Patient Safety Lead, County Durham …	2/2
26 Jul 2016	Terence Adams 2016-wp25340 · ME Hassell Inadequate checking and sharing of prison risk assessments, healthcare staff unawareness of risk score protocols, and failure to follow up on missed …	London London Inner (North)	Care UK HMP Pentonville	1/2
26 Jul 2016	Margaret Tuck 2016-0273 · ME Hassell Multiple failures included an absent falls prevention care plan, incomplete post-fall observations, confusion over nurse responsibility, and delayed investigation of confusion, contributing …	London London Inner (North)	Barts Health NHS Trust	1/1