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 250 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
18 May 2016	Stanley Sampey 2016-0191 · S McGovern The ward lacked working suction equipment due to a flat battery and an incorrect, unstructured checking procedure, posing a risk to patient …	West Midlands Warwickshire	George Eliot Hospital	0/1
17 May 2016	Freda Cordy 2016-0190 · Hassan Shah A patient requiring constant supervision was placed in a care home only offering 2-hourly checks, with no specific falls risk assessment despite …	East Midlands Northamptonshire	Northampton General Hospital Templemore Care Home	0/2
16 May 2016	Jonathan Fry 2016-0193 · Kate Thomas There was a lack of senior consultant review, inadequate daily review of test results, and inconsistent medical records, leading to a lack …	South East Mid Kent and Medway	Medway NHS Foundation Trust	0/1
16 May 2016	Sheldon Woodford 2016-0189 · Sarah Whitby Key safety documents (SASH) are not universally identifiable during reception, and officers receive insufficient training in ACCT processes for managing at-risk individuals.	South East Hampshire Central	HMP Winchester	0/1
16 May 2016	John Crittall 2016-0187 · Karen Henderson An acutely unwell patient was admitted to a private hospital lacking HDU/ITU facilities and emergency protocols. Chest drain insertion was performed against …	South East Surrey	BMI Hospitals Care Quality Commission General Medical Council Royal College of Radiologists	2/5
15 May 2016	Ronnie Olliffe 2016-0224 · Kate Thomas There was a failure to issue a Code Blue appropriately, a lack of understanding about its emergency consequences, and a failure to …	South East Mid Kent and Medway	HMP Rochester	1/1
13 May 2016	Geoffrey Ellis 2016-0186 · Andrew Bridgman Illegible clinical records and incomplete documentation create a serious risk of communication breakdown and misinformation within patient care pathways.	North West Manchester South	Stockport NHS Foundation Trust	1/1
13 May 2016	Harold Davies 2016-0185 · Maria Mulrennan A junction has a history of multiple fatalities, but proposed remedial safety works lack funding and commencement dates. There are also concerns …	East Midlands Nottinghamshire	A-ONE+ Highways England Nottinghamshire County Council	3/3
12 May 2016	Archie Hall 2016-0495 · Nigel Parsley The Orwell Bridge has easily accessible walkways with a low concrete wall offering inadequate fall prevention. There are no physical deterrents or …	East of England Suffolk	Suffolk County Council Highway Department	1/1
12 May 2016	Constance Pridmore 2016-0491 · Paul O’Donnell Rib fractures and a subsequent haemothorax were not identified on admission, leading to undetected blood accumulation and death during a chest drain …	North West Cumbria	Department of Health and Social … University Hospitals of Morecambe Bay …	2/2
12 May 2016	David Aughton 2016-0183 · 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
11 May 2016	Sally Froggatt 2016-0481 · James Adeley There was a failure to comply with the Duty of Candour, inadequate staff training, contradictory corporate guidelines, and nursing staff did not …	North West Preston and West Lancashire	BMI Health Care	0/1
11 May 2016	Mia Gibson 2016-0180 · Heidi Connor Over-reliance on maternal observations in obstetric emergencies overlooked fetal risk, and ambulance dispatch suffered from poor meal break management and resource shortages. …	East Midlands Nottinghamshire	Chair of Association of Ambulance … East Midlands Ambulance Service NHS … NHS Hardwick Clinical Commissioning Group Sustainable Improvement Team, NHS England	0/4
11 May 2016	Gillian Taylor 2016-0178 · Andrew Barkley A lack of acute mental health facilities in Powys forces patients to be moved far from home, causing discontinuity of care and …	Wales South Wales Central	Department of Health and Social … Powys Teaching Health Board	3/2
10 May 2016	Christine Street 2016-0177 · Veronica Hamilton-Deeley Incomplete documentation and a care assistant's failure to adhere to observation policy for a vulnerable patient led to an unwitnessed fall. There …	South East Brighton and Hove	Brighton and Sussex University Hospitals …	1/1
6 May 2016	Jack Susianta 2016-0176 · Mary Hassell Critical information about Jack's expected recovery, symptom recurrence, and urgent help protocols was not communicated to his family, preventing them from seeking …	London London Inner North	East London NHS Foundation Trust	0/1
6 May 2016	Lee Nauman 2016-0175 · Martin Fleming The road surface had a crumbling edge, pothole, and debris, which may have contributed to a loss of control. Review and remedial …	Yorkshire and the Humber Yorkshire West Western	Bradford Metropolitan Borough Council	1/1
6 May 2016	Carole Lovett 2016-0174 · Andrew Walker Staff lacked competence and training in NEW Score usage and communication, leading to alarms not being properly responded to by senior staff, …	London London Greater North	North Middlesex Hospital	0/1
5 May 2016	Ahmedreza Fathi 2016-0173 · Lydia Brown Healthcare complex case planning was inadequate and not updated, multi-disciplinary meetings lacked formalisation and information access, and a prior overdose was not …	East Midlands Leicester City and Leicestershire South	Leicestershire Partnership NHS Trust Northamptonshire Healthcare NHS Foundation Trust East Midlands Ambulance Service NHS … HMP Gartree	2/4
4 May 2016	Tony Jopson and Michael Jopson 2016-0172 · David Roberts The A66's varied road standard, including single carriageway sections, is inadequate for high traffic volumes, particularly HGVs, leading to head-on collisions; it …	North West Cumbria	Department for Transport	1/1