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 246 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
26 Jul 2016	Lee Grimes 2016-wp25332 · Rachael Griffin Home health care failed to act on overdose disclosures and ensure follow-up with mental health services, compounded by inadequate staff training in …	North West Manchester West	5 Boroughs Partnership NHS Foundation … Next Stage	2/2
26 Jul 2016	Rebecca Gilbank 2016-wp25329 · Anna Crawford A check was missed because staff were busy with other service users, and staff lacked knowledge about how to obtain an outside …	South East Surrey	Independence Homes Limited	1/1
25 Jul 2016	Yogalakshmi Sinnaiah 2016-0264 · David Horsley Pedestrians commonly cross the road unsafely at a pelican crossing by "cutting the corner," leading to near misses, suggesting a need for …	South East Portsmouth and South East Hampshire	Department for Transport Hampshire County Council	1/2
25 Jul 2016	Marjorie Nesbitt 2016-0263 · Christopher Dorries Carers lacked training and clear guidance on how to manage unusual and difficult situations, specifically regarding an overheating client from a heater, …	Yorkshire and the Humber South Yorkshire (West)	Sheffield City Council	1/1
25 Jul 2016	Alfie Gray 2016-0262 · Penelope Schofield Inadequate lifeguard provision, including insufficient numbers, lack of medical training, and uncommunicated off-duty periods, created significant safety risks for holidaymakers.	South East West Sussex	British Travel Agents	1/1
25 Jul 2016	Patricia Cleghorn 2016-0270 · Louise Hunt The unavailability of acute mental health beds led to a vulnerable patient being cared for in the community with limited resources, alongside …	West Midlands Birmingham and Solihull	Birmingham and Solihull Mental Health … Care Quality Commission NHS England: Department of Health	4/3
22 Jul 2016	Olawale Adelusi Jeremy Chipperfield There was no effective system to transmit critical information regarding a detained person's self-harm risk and mental health, as detailed observations of …	London London (West)	METROPOLITAN POLICE SERVICE	0/1
22 Jul 2016	Alan Stead 2016-0261 · Andrew Haigh Delays in taking and testing blood samples from prisoners at HMP Dovegate were identified, which could have serious clinical consequences.	West Midlands Staffordshire (South)	Care UK	1/1
22 Jul 2016	Stephen Bird 2016-0265 · Crispin Butler Patient records were incomplete and inconsistent, and the hospital's internal investigation report contained factual assumptions conflicting with documentation, undermining its learning process.	South East Buckinghamshire	BMI The Shelburne Hospital	1/1
21 Jul 2016	Nathan Charman 2016-0267 · Crispin Oliver The winter maintenance policy and decision-making process inadequately addressed extreme or "microclimatic" road conditions, and the incident failed to prompt a formal …	North East County Durham and Darlington	Durham County Council	1/1
19 Jul 2016	Patricia Mercieca 2016-0260 · Dr Fiona Wilcox Call handlers required refresher training on contacting resident managers during emergencies and lacked a protocol for raising immediate concerns when unable to …	London London Inner (West)	Tunstall Response	1/1
19 Jul 2016	Rosemarie Dees 2016-0259 · Henrietta Hills QC An undetected foreign body airway obstruction could inhibit the use of a supraglottic airway, suggesting laryngoscopy should be a prerequisite for SGA …	London London Inner (South)	Resuscitation Council (UK)	0/1
18 Jul 2016	Khazna Khalaf 2016-0489 · Martin Fleming Local protocols and hospital guidelines were ineffective in alerting clinicians to ecstasy toxicity risks and symptoms, lacking a clear clinical protocol for …	Yorkshire and the Humber West Yorkshire (West)	St Marien Hospital Trust	0/1
18 Jul 2016	Sidney Alexander 2016-0257 · PS Cooper Biopsy reports lacked sufficient space for consultants to fully complete their findings, resulting in incomplete and potentially inadequate medical documentation.	East Midlands Lincolnshire (South)	United Lincolnshire Hospitals NHS Trust	0/1
15 Jul 2016	Margaret Gleeson 2016-0255 · Simon Jones Hospital weekend staffing levels were inadequate, leading to poor patient care. The MEWS tool was inaccurately scored and poorly understood, indicating a …	North West Manchester (West)	Wrightington, Wigan and Leigh Teaching …	1/1
15 Jul 2016	Sydney Neil 2016-0256 · Louise Hunt After a patient collapsed in a GP surgery, there was inadequate ventilation, no suction, and no oxygen provided for 8 minutes, raising …	West Midlands Birmingham and Solihull	Birmingham Cross City Clinical Commissioning … NHS England Wychall Lane Surgery	3/3
15 Jul 2016	Leilani Chute 2016-0251 · Bridget Dolan QC Junior doctors used non-standard medical practice without consultant knowledge, and consent for women in labor was not truly informed. Crucially, these issues …	South East West Sussex	St Richard’s Hospital Western Sussex Hospital NHS Trust	1/2
15 Jul 2016	James Kane 2016-0253 · Andrew Tweddle A patient died due to a drain, and a scan potentially could have reduced this risk, indicating a need for further consideration …	North East County Durham and Darlington	County Durham and Darlington NHS … Department of Health and Social …	2/2
14 Jul 2016	Patrick Curran 2016-0258 · Andrew Bridgman Hospital practice condoned nurse-led post-operative reviews and patient discharges without adequate medical overview, even for unwell patients, potentially leading to missed diagnoses …	North West Manchester (South)	South Manchester University Hospital NHS …	1/1
14 Jul 2016	Fred Whittaker 2016-0249 · Andrew Bridgman A patient was erroneously re-prescribed medication due to the lack of a system for recording reasons for stopping drugs and poor prescription …	North West Manchester (South)	Heaton Moor Medical Centre NHS England	1/2