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 247 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
14 Jul 2016	Harold Goulding 2016-0248 · Nadia Persaud Communication breakdown between the care home, GP, and anti-coagulation clinic led to medication mismanagement. The care home lacked systems to inform agencies …	London London (East)	Alexander Court Care Central	1/1
17 Aug 2016	Christine Dryden 2016-0490 · Martin Fleming The absence of regular checks on installed smoke and heat detectors in properties presents a safety risk, necessitating a review of maintenance …	Yorkshire and the Humber West Yorkshire (West)	Incommunities	0/1
12 Jul 2016	Alice Gross 2016-0488 · Fiona Wilcox UK police lack mandatory foreign conviction checks for all arrestees and UK nationals. There are concerns about inadequate international data sharing, "watch …	London London Inner (West)	Home Office	1/1
12 Jul 2016	Steven Billington 2016-0247 · Jennifer Leeming No specific concerns are detailed in the provided text.	North West Manchester (West)	Home Office Secretary for Communities and Local …	2/2
11 Jul 2016	Michael Williams 2016-0245 · Lydia Brown Prison staff missed mandated observations and used predictable intervals for checks. There was an inappropriate delay in responding after a cell observation …	East Midlands Leicester City and Leicestershire South	HMP Leicester	1/1
4 Jul 2016	Henry Hicks 2016-0244 · ME Hassell Police officers failed to identify a situation as a pursuit and seek authorisation, contrary to the jury's determination, implying non-compliance with the …	London London Inner (North)	Metropolitan Police	1/1
4 Jul 2016	Thomas Pearson 2016-0246 · Mark Beresford A patient was prescribed fluticasone, increasing pneumonia risk without benefit due to a non-raised eosinophil count. The coroner recommends reviewing inhaled steroid …	Yorkshire and the Humber South Yorkshire (East)	Doncaster Royal Infirmary	1/1
1 Jul 2016	George Punton 2016-0250 · David Ridley No specific concerns are detailed in the provided text.	South West Wiltshire and Swindon	Highway and Transport Wiltshire Council	1/1
30 Jun 2016	Terence Stilges 2016-0293 · Louise Hunt Repeated incorrect labelling of troponin blood samples resulted in unavailable critical diagnostic information, contributing to delayed diagnosis and patient discharge before subsequent …	West Midlands Birmingham and Solihull	Heart of England NHS Foundation … NHS England	1/2
30 Jun 2016	Luisa Mendes 2016-0243 · Tom Leeper Police call handlers inappropriately categorised violent incidents, and there were no formal handover procedures or training for shift changes. The STORM computer …	West Midlands Warwickshire	Chief Constable of Warwickshire Police	1/1
30 Jun 2016	Dominic Smith 2016-0240 · Lisa Hashmi Antenatal screening for Group B Streptococcus (GBS) was not routinely offered, and intrapartum antibiotics were not routinely offered to women testing positive, …	North West Manchester (North)	Department of Health and Social … N.I.C.E Pennine Acute Hospitals NHS Trust Royal College of Obstetricians	2/5
30 Jun 2016	John Betteridge 2016-0238 · Andrew Tweddle Prison healthcare staff and a GP lacked or had insufficient ACCT training, resulting in non-adherence to mandatory ACCT procedures and indicating a …	North East County Durham and Darlington	G4S National Offender Management Service NHS England Spectrum Community Health	0/4
29 Jun 2016	Peter Rowe 2016-0242 · Andrew Bridgman A patient with severe memory loss was prescribed penicillin despite a documented allergy, which was later deleted. Allergy information was accepted uncritically …	North West Manchester (South)	Central Manchester University Hospitals NHS …	0/1
29 Jun 2016	Lee Davies 2016-0239 · Andrew Barkley Hostel staff lacked specific training on monitoring and safeguarding residents found after illicit drug use, instead only focusing on overdose recognition, leaving …	Wales South Wales Central	Wallich Centre	1/1
28 Jun 2016	David Little 2016-0237 · John Pollard Hospital staff failed to maintain clear radiology records, misidentified a patient, and lacked training to recognise blocked bowel symptoms. Poor inter-departmental communication …	North West Manchester (South)	Tameside Hospital NHS Foundation Trust	1/1
27 Jun 2016	Anielka Jennings 2016-0236 · Katy Skerrett No lead professional was identified for a child transitioning to adult services with multiple agency involvement, leading to a breakdown in communication …	South West Gloucestershire	Gloucestershire Clinical Commissioning Group Gloucestershire County Council	0/2
24 Jun 2016	Kirsty Childs 2016-0497 · Mary Burke At the inquest, it was not possible to trace an appropriate individual from the now defunct NHS direct organisation to give evidence …	Yorkshire and the Humber West Yorkshire (West)	Department of Health and Social … NHS England	0/2
24 Jun 2016	William Nute 2016-0229 · Emma Carlyon Delays in emergency service attendance and patient transfer, coupled with inadequate 999 call triage and police notification, led to an unmanaged incident …	South West Cornwall	Devon and Cornwall Police South Western Ambulance Service	1/2
24 Jun 2016	Richard Hinchliffe 2016-0234 · Philip Barlow Concerns include inadequate security of railway platform barriers and a lack of monitoring for a passenger asleep on the platform for an …	London London Inner (South)	Network Rail	0/1
23 Jun 2016	Michael Younghusband 2016-0235 · John Tomalin A railway crossing point was in a poor state, with a section standing proud of the track, presenting a significant tripping hazard …	South West Exeter and Greater Devon	Great Western Railway	1/1