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 254 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
23 Mar 2016	Mandeep Singh 2016-0116 · Clare Bailey Ambulance arrival was significantly delayed due to severe demand, staff shortages, and challenges presented by road closures and diversions.	North East Teesside	North East Ambulance Service NHS …	1/1
23 Mar 2016	Lincoln Brady 2016-0118 · Clare Bailey Conflicting examination results during labour were not adequately investigated, leading to an undiagnosed breach presentation and preventing appropriate planning for delivery.	North East Teesside	South Tees Hospitals NHS Foundation …	1/1
23 Mar 2016	Alwyn Head 2016-0115 · Patricia Harding Failures included not establishing MRSA history, withholding prophylactic antibiotics, lacking a post-operative wound care plan, and providing meaningless wound documentation, compromising patient …	South East Mid Kent and Medway	Medway NHS Foundation Trust	1/1
22 Mar 2016	Jane Bell 2016-0119 · Alan Wilson Insufficient poolside supervision at the hotel due to infrequent patrols and reliance on CCTV monitored by reception staff who are also busy …	North West Blackpool and Fylde	Dalmeny Hotal	1/1
19 Mar 2016	Ann Jacobs 2016-0111 · Sophie Cartwright There is a lack of consistent 8-hourly potassium level monitoring and adherence to Trust guidance for patients diagnosed with severe hypokalaemia, posing …	East Midlands Derbyshire	Chesterfield Royal Hospital NHS Foundation …	0/1
18 Mar 2016	Jonathan Lander 2016-0114 · Geraint Williams A critical policy for tracking patients discharged between services has not been implemented since 2015, despite being identified as necessary by a …	West Midlands Worcestershire	Worcestershire Health and Care NHS …	1/1
18 Mar 2016	Rubana Pathan 2016-0113 · Mary Hassell Medical professionals and implant manufacturers lack awareness that a rare toxin causing sepsis can suppress typical inflammation signs, potentially delaying diagnosis and …	London London North (Inner)	Homerton University Hospital NHS Trust Johnson and Johnson Medical Devices	1/2
17 Mar 2016	Philmore Mills 2016-0110 · Peter Bedford Police training for subjects with suspected excited delirium lacks instruction on containment tactics and fails to inform officers that restraint take-down procedures …	South East Berkshire	College of Policing National Police Chiefs’ Council	1/2
17 Mar 2016	Jacqueline Scott 2016-0112 · Angela Hodes The BIPAP machine's battery alarm is visually obscured and lacks a distinct sound, hindering staff recognition of critical power loss due to …	London London Inner (West)	Department of Health and Social … Phillips Healthcare St Georges University Hospitals NHS …	2/3
16 Mar 2016	Helen England 2016-0141 · Jennifer Leeming No protocol or guidance exists for Mental Health Nurses regarding doctor referral decisions when discharging self-harm patients, particularly those on a Community …	North West Manchester West	Department of Health and Social …	1/1
16 Mar 2016	Steven May 2016-0109 · Andrew McNamara Prison healthcare suffered from reception nursing staff failing to consult medical notes, lacking mental health expertise, and incomplete ACCT documents. Inadequate First …	East Midlands Nottinghamshire	NHS England HMP Ranby National Offender Management Service Nottinghamshire Healthcare NHS Foundation Trust	2/8
15 Mar 2016	Anna Masson 2016-0108 · G A Short A new mental health referral screening pathway, conducted by junior staff, may not be robust enough to identify urgent cases, and there …	South East Central Hampshire	Southern Health NHS Foundation Trust	1/1
14 Mar 2016	Margaret Metcalfe 2016-0107 · Clare Bailey Both a patient's hand-held buzzer and specialist bed alarm failed to alert staff when she got out of bed, resulting in a …	North East Teesside	Rosedale Care Home	1/1
11 Mar 2016	Amelia Calvo 2016-0192 · Fiona Borrill The death was contributed to by inadequate guarding of an endotracheal tube in a ventilated baby and a critical breakdown in communication …	North West Manchester City	appropriate Royal Colleges Department of Health and Social …	1/2
11 Mar 2016	Jason Vaughan 2016-0105 · Mark Beresford The IAPT electronic patient record system has insufficient narrative detail, and its risk assessment tool cannot track minor patient deterioration. Practitioners may …	Yorkshire and the Humber South Yorkshire (East)	Rotherham, Doncaster and South Humber …	1/1
10 Mar 2016	Derek Nixon 2016-0103 · Ian Smith A lorry driver's elevated cab position prevented seeing a pedestrian crossing directly in front of the vehicle, resulting in a fatal collision …	West Midlands Stoke on Trent and North Staffordshire	Staffordshire County Council	1/1
10 Mar 2016	Charles Newby 2016-0104 · Martin Fleming There are no life rings installed at Lock 19 on the Calder Canal, creating a clear risk of future deaths from drowning.	Yorkshire and the Humber West Yorkshire (Western)	Canal River Trust	0/1
10 Mar 2016	Christine Stevenson 2016-0123 · Joanne Kearsley Large volumes of Oramorph solution, despite containing less than 0.2% morphine, are prescribed without sufficient control. This poses a serious and potentially …	North West Manchester (South)	Medicines and Healthcare Products Regulatory …	2/1
9 Mar 2016	Robert Walker 2016-0494 · Selena Lynch A road bend lacks adequate deviation markings, a tree trunk near the carriageway edge endangers road users, and a path's slippery surface …	London London (South)	Tandridge District Council	0/1
9 Mar 2016	William Higgleton 2016-0131 · Nadia Persaud A critical lack of psychotherapy services for patients with anti-social personality disorder means their primary treatment is unavailable, creating a risk of …	London London (East)	North East London Foundation Trust … Redbridge Clinical Commissioning Group	1/2