Harry Gill
AI-generated concerns summaryThe coroner raises concerns about the robustness of the NHS 111 vomiting pathway, noting that only one out of four calls received an appropriate response.
Addressed to: NHS Digital
Source · Prevention of Future Deaths
Prevention of Future Deaths Reports
Browse 6,488 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.
Reports
Peter Lawrence
AI-generated concerns summaryThe coroner identified that risk factors may be missed or inadequately recorded for new prisoners, particularly those with limited background information. Further concerns included insufficient interaction with a personal officer, a missed opportunity for risk identification.
Addressed to: National Offender Management Service
Robert Dearing
AI-generated concerns summaryThe coroner noted that unregulated, non-standard anti-glare visors significantly reduced driver vision due to low Visual Light Transmission, and there is no specific legislation or British Standard for such devices.
Addressed to: Department for Transport
Kyles Lowes
AI-generated concerns summaryThe coroner raised concerns about extended emergency care journey times from Berwick-upon-Tweed and the risks posed by having only one paramedic crew after 10 p.m., especially when the crew is unavailable due to breaks or out-of-area duties.
Addressed to: NEAS NHS Trust; NHS Northumberland Clinical Commissioning Group
Maureen Flynn
AI-generated concerns summaryThe coroner noted a falls risk assessment for Mrs. Flynn was incomplete, and care staff were unaware. The report identifies a need for a system to alert staff to incomplete assessments, an issue also not identified by the patient safety investigation.
Addressed to: Stepping Hill Hospital
Pamela Conway
AI-generated concerns summaryThe coroner raises concerns regarding ongoing unacceptable delays for patients waiting in ambulances, which also makes ambulance resources unavailable. Additionally, patient flow problems persist within Maelor Hospital's Emergency Department.
Addressed to: Betsi Cadwaladr University Health Board; Welsh Ambulance Services NHS Trust
Raymond Woodward
AI-generated concerns summaryThe coroner noted that the risk of an adverse reaction to Buscopan in patients with coronary artery disease is not widely known. The current SPC for intravenous Buscopan lacks specific caution for those with ischaemic heart disease, suggesting a need for clearer guidance.
Addressed to: Medicines and Healthcare Products Regulatory Agency
Joyce Ravenhill
AI-generated concerns summaryThe coroner noted a lack of operational policy or facility for triage nurses to effectively communicate the need for an urgent doctor's appointment when information was automatically electronically generated.
Addressed to: North West Ambulance Service Trust NHS
Stephen Cahill
AI-generated concerns summaryThe coroner noted easy access to the railway line through an access gate and fence that offered little deterrence. A recommended review of the fencing and access gates at that location has not been undertaken.
Addressed to: Network Rail
Michael Dundon
AI-generated concerns summaryThe coroner notes that liquid absorbing crystals, which can be mistaken for sugar, were swallowed by the deceased from pre-inserted sachets. Concerns are raised about staff understanding of associated risks and the need for nationwide risk assessments and training.
Addressed to: Department of Health and Social Care
Nicholas Sullivan
AI-generated concerns summaryThe coroner noted the absence of a checklist for emergency department staff to identify mental health issues and trigger urgent triage. Concerns also included no clear system for patient safeguarding or escalation, and insufficient inter-trust protocols.
Addressed to: Manchester Mental Health and Social Care Trust; North Manchester General Hospital
Nathan Lowe
AI-generated concerns summaryThe coroner raised concerns regarding whether more active efforts should have been made to contact the patient between 10th March and 12th May, considering his illness and non-compliance with follow-up.
Addressed to: Hertfordshire Partnership University NHS Foundation Trust
John Jones
AI-generated concerns summaryThe coroner identified a suboptimal therapeutic environment where a patient admitted for group therapy remained largely isolated and did not engage with available sessions. Concerns were raised about ensuring patient engagement when their condition makes accepting help difficult.
Addressed to: Consultant Psychiatrist, Keats House, London; Nightingale Hospital
Amanda Coppen
AI-generated concerns summaryThe coroner noted that the unusual layout of Pilot Busway and West Parkside may mislead road users, causing pedestrians to look the wrong way. The planned opening of a new school nearby is expected to increase pedestrian traffic, raising safety risks for schoolchildren at the junction.
Addressed to: Lands, Estates and Property Housing and Land Directorate, Greater London Authority; Royal Borough of Greenwich; Surface Transport, Transport for London
Margaret Richardson
AI-generated concerns summaryThe coroner noted the need for a robust and comprehensive action plan with timescales, to be implemented following a Serious Incident Investigation and inquest findings.
Addressed to: North Essex Mental Health Partnership Trust
George Watson
AI-generated concerns summaryThe coroner identified an unsatisfactory patient discharge process, specifically regarding medication provision, and unclear procedures for staff allocation and managing staff absence. There was also a call for further evidence on improved investigatory processes, including police cooperation.
Addressed to: University Hospital, Coventry; University Hospitals Coventry and Warwickshire NHS Trust
Diana Ritchie
AI-generated concerns summaryThe coroner identified missed opportunities to escalate care due to un-reported and inaccurately recorded NEWS scores, alongside insufficient frequency of observations during deterioration. A wider need for training on proper NEWS use within the Trust was also highlighted.
Addressed to: Brighton and Sussex University Hospitals NHS Trust
Jonathan Sellman
AI-generated concerns summaryThe coroner raised concerns regarding water pooling on a busy road and the state of the verges, which could potentially cause vehicles leaving the road to be pushed over safety barriers.
Addressed to: Rotherham Borough Council
Harry Glibbery
AI-generated concerns summaryThe coroner noted a doctor did not prescribe Clexane according to protocol, and this error was not identified during pharmacy reviews. Concerns were also raised about difficulties in weighing patients, which is crucial for weight-dependent medication.
Addressed to: Plymouth Hospitals NHS Trust
Micael McMonigle
AI-generated concerns summaryThe coroner identified gaps in staff knowledge and adherence to policies for informal patient leave, leading to inadequate risk assessments and unclear communication of leave conditions. Significant delays and non-compliance with missing patient procedures were also noted.
Addressed to: Tees, Esk and Wear Valley NHS Trust