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.

Response tracker Organisations Advanced search

Keyword

Browse by year

Browse by region

Sort

Reports

6,383 reports · Page 248 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
22 Jun 2016	Malcolm Bennett 2016-0232 · John Pollard Staff at the care home delayed calling an ambulance for three hours after a significant injury, despite the care plan requiring immediate …	North West Manchester (South)	Borough Care Ltd	1/1
21 Jun 2016	Olive Wilmott 2016-0231 · Stephanie Haskey An alleged assault was not effectively investigated or safeguarded, and the care home failed to meet observation requirements due to insufficient night …	East Midlands Nottingham	Ideal Care Home Ltd	0/1
20 Jun 2016	Zawdie Bascom 2016-0227 · Nadia Persaud Inadequate pain assessment and management in A&E, including missing pain scores on triage and after analgesia, led to unmitigated severe pain at …	London London (East)	Barts Health NHS Trust	0/1
20 Jun 2016	Stephanie Marks 2016-0233 · S Fox QC There was no evidence of a system to ensure daily GP messages were consistently countersigned and acted upon by general practitioners.	South West Avon	Clevedon Medical Centre	0/1
20 Jun 2016	Michael Hutchence 2016-0228 · John Pollard Concerns included frequent, unnecessary ward transfers, poor medical record-keeping, care by unqualified staff, and inaccurate anticoagulant dosing due to weight recording issues. …	North West Manchester (South)	Stockport NHS Foundation Trust	1/1
16 Jun 2016	Reece Atkinson 2016-0226 · Anna Crawford The accumulation of wet soil and sandy deposits on the A25 Sheer Road, near a sandpit entrance, creates a road hazard for …	South East Surrey	Surrey County Council	0/1
16 Jun 2016	Valerie Ellis 2016-0252 · David Skipp Inadequate discharge counselling for a vulnerable patient on medication, coupled with concerns about 111 health advisor training and imprecise algorithms. A call-back …	South East West Sussex	IC24 SECAMB Western Sussex Hospital NHS Trust	3/3
14 Jun 2016	Christina O’Brien 2016-0221 · Christopher Williams Limited community respite care options for mentally ill individuals, with the withdrawal of beneficial facilities like "Dove House" without alternative provision, preventing …	London London Inner (South)	Department of Health and Social … South London and Maudesley NHS …	0/2
13 Jun 2016	Laura McRory 2016-0223 · Nadia Persaud The Trust lacked a clear process for employees seeking mental health care, especially regarding confidentiality and external referrals. There was also an …	London London (East)	North East London NHS Foundation …	1/1
13 Jun 2016	Kinga Cieciorska 2016-0222 · Zafar Siddique A missed opportunity to investigate abnormal ECG trace and tachycardia; systemic failings in recording and transmission of information, with GP medical notes …	West Midlands Black Country	Walsall Healthcare NHS Trust	0/1
13 Jun 2016	Kevin Dermott 2016-0220 · Nicholas Rheinberg While at HMP Durham, the deceased was left in a urine soaked cell during a hypomanic episode and a psychiatric referral was …	North West Cheshire	Department for Health NHS England	3/2
9 Jun 2016	Matthew Gunn 2016-0217 · Katy Skerrett An epileptic event experienced by an employee at work was not officially recorded, raising concerns about incident reporting protocols.	South West Gloucestershire	DWF LLP W M Morrisons PLC	1/2
8 Jun 2016	Anthony Fraser 2016-0225 · Nicola Mundy Summary medical information was not conveyed to the receiving A&E department upon transfer, and there is no system for ensuring such information …	Yorkshire and the Humber South Yorkshire (East)	HMP Lindholme	1/1
8 Jun 2016	Gwendoline Clarke 2016-0218 · Katy Skerrett Staff failed to report a resident's injury and delayed escalating allegations of abuse for approximately 12 hours.	South West Gloucestershire	ADL PLC Care Quality Commission	1/2
28 Jun 2016	Tommi-Ray Vigrass 2016-0241 · Zafar Siddique A paediatric doctor made an erroneous extubation decision without consulting a consultant. There were also delays in contacting a tertiary unit and …	West Midlands Black Country	Care Quality Commission Walsall Healthcare NHS Trust	1/2
8 Jun 2016	Stephen Hunt 2016-0216 · Nigel Meadows Fire and Rescue Services lacked adequate measures for managing heat stress in hot environments, had poor communication protocols, and insufficient training/SOPs for …	North West Manchester (City)	Chief Fire and Rescue Services Home Office	2/2
8 Jun 2016	Peter Seale 2016-0215 · Lisa Hashmi The absence of national guidance for monitoring patients with pleural plaques leads to inconsistent follow-up, risking delayed diagnosis and treatment.	North West Manchester (North)	Department of Health and Social … Royal College of Physicians	0/2
6 Jun 2016	Ezharul Islam 2016-0214 · Andrew Walker There is no system in place to alert bus passengers when the vehicle is about to move, unlike previous methods which involved …	London London (North)	Transport for London	1/1
6 Jun 2016	Tracey Lynch 2016-0211 · Michael Singleton No specific concerns are provided in the truncated text.	North West Blackburn, Hyndburn and Ribble Valley	Lancashire Care NHS Foundation Trust	0/1
6 Jun 2016	Steven Trudgill 2016-0210 · Peter Dean HM Prison Service lacked standardised treatment programs for fire setters with complex mental health issues, and a suggested therapeutic community option for …	East of England Suffolk	Ministry of Justice	0/1