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 251 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
4 May 2016	Michael Jopson 2016-wp25249 · David Roberts The A66 is a mix of dual carriageway and winding country road, and the coroner suggests that from a road safety perspective …	North West Cumbria	Department for Transport	1/1
3 May 2016	Shalane Blackwood 2016-0179 · Stephanie Haskey The prison lacks adequate provision for complex health needs, has insufficient staff for prisoner regimes, faces rife NPS use, and has unclear …	East Midlands Nottinghamshire	HMP Nottingham HM Prison and Probation Service NHS England Nottingham Healthcare NHS Trust	0/4
3 May 2016	Darren Mindham 2016-0170 · Selena Lynch Pentobarbital, a Schedule 3 drug, is frequently used in suicides due to less strict controls; stricter regulation could reduce suicide rates.	London London South	Department of Health and Social …	1/1
3 May 2016	Mihangel ap Dafydd 2016-0169 · Jonathan Layton Windows in Morlais Ward service user areas are not ligature-free, posing a safety risk, and planned remedial work has not yet been …	Wales Carmarthenshire and Pembrokeshire	West Wales General Hospital	2/1
30 Apr 2016	William Thompson 2016-0130 · ME Hassell A high-risk service user lacked a smoke detector in his bedroom; social workers failed to assess or address this significant fire safety …	London London Inner (North)	London Borough of Hackney	1/1
29 Apr 2016	Jack Molyneux 2016-0168 · Veronica Hamilton-Deeley VERONICA HAMILTON-DEELEY, LLB_.	South East Brighton and Hove	Brighton Sussex University Hospitals NHS …	0/1
29 Apr 2016	Jan Bodnar 2016-0166 · Graham Danbury Dangerous plant growth on a central reservation severely restricted driver visibility at a junction, requiring regular maintenance and review of similar junctions.	East of England Hertfordshire	Hertfordshire County Council	1/1
28 Apr 2016	Thomas Harris 2016-wp25258 · Rachel Redman Helium's easy availability online and on the high street, along with the size and valve of canisters, facilitates its use in suicide …	South East Kent Central and South East	Right Honourable Theresa May MP	0/1
28 Apr 2016	Patrick McGagh 2016-0171 · John Pollard A patient was discharged without a discharge letter or prescribed antibiotics being provided to his GP or care staff, leaving them unaware …	North West Manchester South	South Manchester University Hospital NHS …	1/1
28 Apr 2016	Laxmi Thakker 2016-0165 · Fiona Wilcox Deficiencies included inadequate observation charts, poor staff training on critical care teams, communication issues, flawed blood administration systems, and significant failures in …	London London Inner West	Croydon University Hospital and NHS …	0/1
27 Apr 2016	Kathryn Bull 2016-0188 · Henrietta Hill Death was caused by hyperammonaemia syndrome, a rare and poorly understood adverse consequence of gastric bypass surgery, with symptoms that are not …	London London Greater Inner South	British Obesity and Metabolic Surgery …	0/1
27 Apr 2016	Ernest Higgs 2016-0181 · Caroline Topping Confusion arose from unrecorded GP advice in multi-disciplinary notes and unconfirmed telephone advice. Conflicting information between care providers also caused significant delays …	South East Surrey	British Medical Association Care UK Epsom and St Helier University … Linden House Surgery	3/6
27 Apr 2016	Caragh Melling 2016-0167 · R Brittain The current NHS Pathways triage system lacks a crucial breathing analysis tool for identifying agonal breathing, a concern raised nationally since 2014 …	London London Inner North	NHS Pathways	0/1
27 Apr 2016	Steven Murphy 2016-0164 · David Horsley South West Trains failed to respond positively to a British Transport Police report recommending measures to reduce the risk of people climbing …	South East Portsmouth and South East Hampshire	South West Trains	0/1
27 Apr 2016	Christopher Holyoake 2016-0163 · Christina Swann E45 cream, a highly flammable paraffin-based product, lacked fire hazard warnings on its packaging and prescription, leading to a dangerous lack of …	East Midlands Leicester City and Leicestershire South	Commissioning and Operations, Centra Midlands … Fire Officers Association Reckitt Benckisher Healthcare (UK) Ltd	3/3
25 Apr 2016	Marjorie Wood 2016-0161 · Joanne Kearsley There is a lack of clear understanding about the legal status of individuals in care homes, which can negatively impact their care …	North West Manchester South	Kingsley Care Home Timperley Care Home	1/2
25 Apr 2016	Norma Holden 2016-0160 · Jean Harkin The inquest identified matters of concern presenting a risk of future deaths if not addressed, requiring action by the relevant authorities.	North West Manchester City	University of Manchester NHS Foundation …	0/1
22 Apr 2016	Marina Fagan 2016-0162 · R Brittain A nationwide shortage of neurologists leads to significant delays in accessing specialist care, including long outpatient waiting times and lack of out-of-hours …	London London Inner North	Department of Health and Social …	1/1
21 Apr 2016	Richard Grant 2016-0157 · Emma Brown Critical delays occurred in referring a patient who attempted suicide to the correct mental health team, and the GP was not promptly …	West Midlands Birmingham and Solihull	Black Country Partnership NHS Foundation …	1/1
21 Apr 2016	Margaret Rogerson 2016-0155 · M Jennifer Leeming Care home staff lacked adequate training in safe patient feeding techniques and associated risks, with no refresher courses. Family members also lacked …	North West Manchester West	BUPA Mill View Nursing Home Right Honourable Jeremy Hunt MP	0/3