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 249 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
2 Jun 2016	Jessica Birkhead 2016-0208 · John Tomalin Mainstream adult support services were ill-equipped to provide appropriate care for individuals with intellectual disabilities, suggesting a need for a specific pathway …	South West Exeter and Greater Devon	Northern, Eastern and Western Devon … Seaton and Colyton Medical Practice	2/2
2 Jun 2016	Clarice Hilton 2016-0207 · Rachael Griffin Psychiatric units lack a policy or guidance for staff on how to manage patients who refuse physical health observations, leading to critical …	North West Manchester (West)	5 Borough Partnership NHS Trust	1/1
2 Jun 2016	Jonathan Weatherley 2016-0206 · Caroline Beasley-Murray Recall notices for the products were inadequate, failing to highlight all known problems and affected items, necessitating a comprehensive, widely distributed new …	East of England Essex	Trading Standards	0/1
1 Jun 2016	Rhianne Barton 2016-0213 · Karen Henderson Lack of obstetric consultant supervision, failure to consider surgical causes despite bariatric history, and poor documentation of observations contributed to delayed diagnosis …	South East Surrey	Ashford and St Peter Hospital CQC General Medical Council Medical Care Council	1/5
31 May 2016	Danielle Robinson 2016-0205 · John Gittins Staff are not rigorously following the Therapeutic Engagement and Observation Policy, leading to missed opportunities for escalating patient observation levels during critical …	Wales North Wales (East and Central)	Betsi Cadwaladr University Health Board	1/1
27 May 2016	Adetokunbo Ajakaiye 2016-0209 · Mark Beresford Prison healthcare staff lacked essential knowledge and practical experience regarding malaria and tropical diseases, posing a significant risk in an era of …	Yorkshire and the Humber South Yorkshire (East)	Ministry of Justice NHS England	0/2
27 May 2016	Charlie Jermyn 2016-0204 · Elizabeth Carlyon Systemic failings included significant delays in labour assessment, inadequate routine physiological observations, lack of standard equipment for community midwives, and inappropriate triage …	South West Cornwall	Kernow Clinical Commissioning Group NHS England Royal Cornwall Hospital, Treliske, Truro	0/3
27 May 2016	Esmee Polmear 2016-0203 · Elizabeth Carlyon Failure to routinely use respiratory rate benchmarks, oxygen blood monitoring, and recognise critical red markers in paediatric respiratory medicine hindered diagnosis and …	South West Cornwall	Kernow Clinical Commissioning Group NHS England	0/2
27 May 2016	Keenan Walsh 2016-0202 · Elizabeth Earland Unregulated private holiday swimming pools, non-standard pool design, and inadequate adult supervision ratios created significant safety hazards for children.	South West Exeter and Greater Devon	Devon County Council North Devon Council	2/2
26 May 2016	Ian Brown 2016-0200 · Thomas Osborne Despite previous recommendations, HMP Woodhill has failed to rigorously implement strategies to reduce self-inflicted deaths, resulting in continued rises in suicide and …	South East Milton Keynes	HMP Woodhill Minister for Prisons	1/2
26 May 2016	Peter Scott 2016-0199 · Heidi Connor The ambulance service is critically under-resourced, operating frequently under severe capacity constraints due to high demand and recruitment issues, exacerbated by hospital …	East Midlands Nottinghamshire	NHS Improvement Department of Health and Social … East Midlands Ambulance Service NHS England	4/5
25 May 2016	Christopher Sears 2016-0212 · Karen Henderson Bus drivers transporting students are not required to have Basic Life Support training or emergency protocols, and BLS is not routinely taught …	South East Surrey	Department for Education Department for Transport Greenshades Coach Travel Ltd George Abbot School	2/5
25 May 2016	Patricia Steer 2016-0201 · Jacqueline Devonish Nursing staff performing catheter changes were unaware of the risk of air embolization from uncapped/unclamped catheters, and there was a lack of …	London London Inner (North)	NHS England	1/1
24 May 2016	Beverley Siddall 2016-0230 · Emma Carlyon The road layout, safety notices, and barriers on a specific section of the A3075 are inadequate, posing a persistent risk of vehicles …	South West Cornwall	Cornwall Council	1/1
24 May 2016	Simon Klineberg 2016-0198 · Guy Davies Concerns include insufficient psychiatric bed availability, inadequate resourcing for home treatment teams, and significant waiting lists for psychological therapy, especially for high-risk …	South West Isles of Scilly	Cornwall Partnership NHS Foundation Trust NHS Kernow Clinical Commissioning Group	0/2
23 May 2016	Sadie Peters, Joseph Peters and George Peters 2016-0219 · Richard Travers Inadequate awareness programmes exist for the importance of fitting and maintaining smoke detectors in mobile and static caravans, increasing fire safety risks.	South East Surrey	Surrey Fire and Rescue Service Caravan Club Showmen’s Guild of Great Britain	2/3
23 May 2016	Karen Ravenscroft 2016-0197 · Michael Singleton The concerns text for this report is incomplete, so specific issues cannot be identified.	North West Blackburn, Hyndburn and Ribble Valley	East Lancashire Healthcare NHS Trust	0/1
19 May 2016	Samuel Blair 2016-0196 · ME Hassell Prison healthcare failed to adequately assess mental health, record vital information, or continue prescribed antidepressants. Delays in emergency response included slow 999 …	London London Inner (North)	Care UK HMP Pentonville London Ambulance Services NHS Trust National Offender Management Service	3/4
18 May 2016	Ratidzai Sangare 2016-0195 · Selena Lynch Healthcare staff failed to recognize a critical condition requiring immediate resuscitation and delayed alarm response due to assumptions. Agency staff had limited …	London London South	Oxleas NHS Foundation Trust	0/1
18 May 2016	Christopher Fields 2016-0194 · John Pollard Police left a vulnerable, injured person in an unsafe situation without awaiting an ambulance, leading to further assault. Ambulance dispatch algorithms are …	North West Manchester South	Department of Health and Social … Greater Manchester Police NHS England North West Ambulance Service	4/4