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 252 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
21 Apr 2016	Christopher Brand 2016-0154 · Peter Bedford Hospital staff failed to follow observation policy due to obscured views and delayed checking on a patient's welfare. Crucially, CPR was not …	South East Berkshire	Broadmoor Hospital	1/1
21 Apr 2016	Derrick Rose-Fowler 2016-0153 · John Ellery A prison officer lacked first aid training, potentially delaying CPR, and the bullying policy was ineffective for prisoners unwilling to name names. …	West Midlands Shropshire, Telford and Wrekin	HMP Stoke Heath Ministry of Justice	0/2
21 Apr 2016	Keith Harper 2016-0151 · Caroline Beasley-Murray Drivers lacked adequate warning of a pedestrian crossing near a roundabout due to limited visibility and misleading road features. Additionally, carriageway markings …	East of England Essex	National Highways	1/1
21 Apr 2016	Mary Walker 2016-0150 · Alison Mutch Night-time patient checks lacked specific details on patient condition, and there was unclear guidance for care assistants on escalating health concerns. Both …	North West Manchester West	Belong Village Care Quality Commission	2/2
20 Apr 2016	Angus West 2016-0158 · David Hinchliff The placenta was not retained after a baby's death, impeding a comprehensive post-mortem examination to determine the cause, such as infection or …	Yorkshire and the Humber Yorkshire West (Eastern)	York Teaching Hospitals NHS Foundation …	2/1
20 Apr 2016	Helen Patton 2016-0152 · Karen Dilks Mini Tracheostomy Procedures pose an ongoing mortality risk due to being frequently performed outside theatre and without ultrasound guidance. A critical lack …	North East Newcastle Upon Tyne	Department of Health and Social …	2/1
20 Apr 2016	Ronald Hamer 2016-0149 · Graeme Hughes An ambulance response was critically delayed by over two hours, and no follow-up calls were made to the patient's family. This was …	Wales South Wales Central	Health Inspectorate Wales Minister for Health and Social … Welsh Ambulance Service NHS Trust	1/3
19 Apr 2016	Corey Price 2016-0146 · Andrew Barkley An advanced warning sign of the approaching left bend on the A470 would assist in warning motorists of the nature of the …	Wales South Wales Central	Powys County Council	0/1
19 Apr 2016	Alesha O’Connor 2016-0146-wp25227 · Andrew Barkley An advanced warning sign of the approaching left bend on the A470 would assist in warning motorists of the nature of the …	Wales South Wales Central	Powys County Council	0/1
19 Apr 2016	Margaret Challis 2016-0146-wp25226 · Andrew Barkley An advanced warning sign of the approaching left bend on the A470 would assist in warning motorists of the nature of the …	Wales South Wales Central	Powys County Council	0/1
19 Apr 2016	Rhodri Miller-Binding 2016-0146-wp25225 · Andrew Barkley A "challenging" A470 road stretch with a history of serious collisions lacks adequate warning signs for an approaching left bend. An advanced …	Wales South Wales Central	Powys County Council	0/1
19 Apr 2016	Leslie Carswell 2016-0147 · Louise Hunt Technical difficulties in transmitting CT scans between trusts caused critical delays in deciding treatment plans for urgent conditions. These unresolved issues risk …	West Midlands Birmingham and Solihull	Sandwell and West Birmingham NHS … University Hospital Birmingham NHS Foundation …	1/2
18 Apr 2016	Carl Thompson 2016-0492 · Martin Fleming Life-saving equipment used by lifeguards was defective or missing, including a defibrillator without batteries, causing significant resuscitation delays. There were also concerns …	Yorkshire and the Humber West Yorkshire (West)	Carralejo Fuerteventura Foreign and Commonwealth Office	0/2
18 Apr 2016	Doreen Mattinson 2016-0156 · Jacqueline Devonish Oxygen was incorrectly administered at a care home, with staff failing to recognise appropriate emergency oxygen levels and positioning. The clinical manager, …	London London Inner North	Acorn Lodge Care Home	0/1
15 Apr 2016	Luke Ayres 2016-0148 · Emma Brown Delays in emergency response were caused by a cut-off 999 call, a staff member providing ambulance information from a distance without current …	West Midlands Birmingham and Solihull	Birmingham and Solihull Mental Health …	1/1
15 Apr 2016	Adele Blakeman 2016-0145-wp25219 · Joanne Kearsley The antiquated GMP computer system hinders officers' access to critical information, preventing adequate situation assessment. Officers also failed to consistently record pertinent …	North West Manchester South	Greater Manchester Police	1/1
14 Apr 2016	Helen Turner 2016-0159 · Helen Redman Critical delays in diagnosing a sigmoid colon obstruction and subsequently performing stenting and surgery led to a severe deterioration in the patient's …	South East Kent Central and South East	East Kent Hospitals University NHS …	0/1
12 Apr 2016	Hayley Clark 2016-0143 · Mark Beresford Staff failed to adjust the paracetamol dosage to reflect the patient's extremely low body weight, indicating a lack of appropriate medication management.	Yorkshire and the Humber Yorkshire South (East District)	Rotherham Hospital NHS Foundation Trust	1/1
12 Apr 2016	Dennis Bennett 2016-0142 · Joanne Kearsley There was a significant lack of understanding among Trust staff regarding Deprivation of Liberty Safeguards (DOLS) applications, their "place-specific" nature, and their …	North West Manchester South	Greater Manchester West Mental Health … Trafford Council	1/2
7 Apr 2016	Joyce Carney 2016-0140 · Alan Walsh Fragmented risk assessments and a lack of communication between police and hospital staff led to a misunderstanding of the ward layout, inadequate …	North West Manchester West	Department of Health and Social … Greater Manchester Police Home Office Leigh NHS Foundation Trust	3/5