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.

Response tracker Organisations Advanced search

Keyword

Browse by year

Browse by region

Sort

Reports

6,383 reports · Page 253 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
7 Apr 2016	Matthew Sargent 2016-0138 · Geraint Williams Critical information sharing failures occurred as historical prisoner data and ACCT histories were not consistently reviewed or shared with healthcare staff upon …	West Midlands Worcestershire	Government Legal Department Worcestershire Health and Care NHS …	2/2
7 Apr 2016	Nadim Butt 2016-0137 · Ian Smith The hospital failed to conduct a serious untoward incident review or root cause analysis, limiting critical examination of decisions. Additionally, a necessary …	West Midlands Stoke-on-Trent and North Staffordshire	University Hospital of North Midlands	0/1
6 Apr 2016	Milly Zemmel 2016-0139 · Nigel Meadows There were gross failures in applying the falls risk policy, escalating clinical review, providing one-to-one supervision, and handing over critical patient information, …	North West Manchester City	North Manchester General Hospital	1/1
6 Apr 2016	Vincent Smith 2016-0134 · Derek Winter The nursing home failed to adequately assess and act upon a resident's vulnerability to falls. Concerns were raised regarding the admissions policy, …	North East Sunderland	Village Nursing and Care Home	0/1
6 Apr 2016	Monica Lewis-Hinds 2016-0133 · Selena Lynch The ambulance service's call triage protocol is inadequate as call handlers do not proactively ask about the "type of fit," potentially missing …	London London (South)	London Ambulance Service	0/1
5 Apr 2016	Dorothy Imisson 2016-0496 · James Adeley The District Nursing Service compromised patient care by failing to develop appropriate care plans and not following NMC guidance for record-keeping or …	North West Preston and West Lancashire	Blackpool Teaching Hospitals NHS Trust Care Quality Commission	0/2
5 Apr 2016	Mark Seward 2016-0136 · David Clark A lack of clarity on pressure testing definitions and widespread non-compliance with work equipment regulations (PUWER) and HSE guidance across the industry …	West Midlands Warwickshire	AGD Equipment Limited Construction Plant Hire Association	1/2
4 Apr 2016	Kristian Jaworski 2016-0125 · Andrew Walker A presumption in favour of vaginal delivery, partly driven by cost, needs to be re-evaluated to ensure patient safety and appropriate medical …	London London (North)	Department of Health and Social …	1/1
1 Apr 2016	Lillian Hursell 2016-0129 · Patricia Harding Faulty bedrail mechanisms led to instability, and staff provided inappropriate first aid after a patient's fall by moving her without assessing potential …	South East Mid Kent and Medway	Ranc Care Home Ltd	1/1
1 Apr 2016	Arthur Mason 2016-0128 · Jacqueline Lake Staff lacked formal risk assessment training and failed to identify risks for farm tasks, compounded by the absence of a comprehensive emergency …	East of England Norfolk	Maurice Mason Ltd	1/1
1 Apr 2016	Roy Oakley 2016-0126 · Eleanor McGann No specific concerns were detailed in the provided text.	East of England Essex	Basildon Hospital Trust	0/1
31 Mar 2016	David Curtis 2016-0144 · John Tomalin Inconsistent and inadequate road signage fails to warn motorists of a critical left-hand bend immediately beyond a hill crest, unlike the opposite …	South West Exeter and Greater Devon	Devon County Council Devon Highways	1/2
31 Mar 2016	Sheila Slater 2016-0127 · ARW Forrest The staggered junction of the A16 with the B1166 is part of the Crowland Bypass which was pened in 2010 and there …	East Midlands South Lincolnshire	Department for Transport	1/1
31 Mar 2016	John Watt 2016-0124 · Simon Wickens The lack of a safe or controlled pedestrian crossing on the main A25 road in Abinger Hammer village poses a significant risk …	South East Surrey	Surrey Local Highways Services Group …	1/1
30 Mar 2016	Steven Nicholson 2016-0135 · Karen Dilks The A1018 slip road lacks appropriate lighting to identify sudden hazards and crucial signage warning motorists of flooding risks.	North East Newcastle Upon Tyne	Durham County Council	1/1
29 Mar 2016	Adam Miles 2016-0132 · David Urpeth The hotel allowed smoking near the canal without adequate barriers to prevent falls, and the canal itself lacked any means of escape …	Yorkshire and the Humber South Yorkshire (West)	British Waterways Canal and River Trust Hilton Hotel	2/3
29 Mar 2016	Pamela Thurston 2016-0122 · Johanna Thompson The care home failed to update the care plan for a patient with a choking risk and left her unsupervised to eat …	East of England Norfolk	Caring Homes Healthcare Group Limited Cedar Care Home	1/2
29 Mar 2016	Dorota Kijowska 2016-0121 · Caroline Beasley-Murray The outcome of a critical review meeting was not formally signed off by attendees nor clearly communicated to the patient, leading to …	East of England Essex	North Essex Partnership University NHS …	0/1
23 Mar 2016	June Parkes 2016-0493 · Mary Burke Significant delays occurred in urgent endoscopies due to inadequate protocols for 'in-hours' care and re-bleeds, and a lack of 'out-of-hours' emergency endoscopy/surgery. …	Yorkshire and the Humber West Yorkshire (West)	Calderdale Royal Hospital	0/1
23 Mar 2016	Alan Dimbleby 2016-0120 · Richard Travers Self-propelled sprayers lack operator seat restraints, risking operators being thrown from the vehicle if it overturns. HSE guidance may inappropriately suggest these …	South East Surrey	Bateman Engineering Ltd Health and Safety Executive the appropriate authority in Portugal	2/3