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 255 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
9 Mar 2016	John Rogers 2016-0097 · John Adrian Gittins The health board's current systems are inadequate to ensure staff possess appropriate and up-to-date qualifications and training for their required work.	Wales North Wales (East and Central)	Betsi Cadwaladr University Health Board	1/1
8 Mar 2016	Elsie Tindle 2016-0098 · Derek Winter The insufficient number of Second Opinion Appointed Doctors (SOADs) leads to delays, causing practitioners to default to urgent powers for ECT, risking …	North East Sunderland	Department of Health and Social …	1/1
7 Mar 2016	Patricia Thomas 2016-0096 · Paul Bennett A significant lack of awareness among health professionals regarding the dangerous interaction between Miconazole Gel and Warfarin, combined with unclear information resources, …	Wales Swansea	BMA General Dental Council NHS England: Wales and Scotland Royal College of GPs	0/5
4 Mar 2016	Lee Gaunt 2016-0092 · John Pollard The Fire and Rescue Service failed to provide effective occupational health support, assigning extra duties to a distressed employee after a colleague's …	North West Manchester South	Greater Manchester Fire and Rescue …	1/1
4 Mar 2016	Elsie Raper 2016-0090 · Crispin Oliver A patient's severe tibia and fibula fractures remained undiagnosed for four days despite regular medical visits, leading to extreme pain and contributing …	North East County Durham and Darlington	County Durham and Darlington NHS … Neasham Road Surgery	2/2
4 Mar 2016	Marjorie Booth 2016-0094 · John Pollard Concerns were raised about an apparent hospital policy not to routinely perform CT scans for suspected fractures, even when the risk of …	North West Manchester (South)	Stockport NHS Foundation Trust	0/1
4 Mar 2016	Ranjan Mistry 2016-0093 · John Pollard There was no, or insufficient, assessment of the deceased's Falls Risk, neurological observation charts were incomplete or lost, and medical staff were …	North West Manchester (South)	Tameside Hospital NHS Foundation Trust	1/1
3 Mar 2016	Stewart Akins 2016-0091 · David Reid Critical information about the deceased's repeated suicide intentions recorded in police custody was not relayed to the Magistrates' Court, leading to bail …	West Midlands Worcestershire	West Mercia Constabulary	1/1
3 Mar 2016	Aleeza Ahmed 2016-0089 · John Pollard Chamfered kerbstones and the absence of a protective Armco barrier on a central reservation were identified as potential factors contributing to a …	North West Manchester (South)	Stockport Council	1/1
6 Mar 2016	Edward Paddon-Bramley 2016-0099 · Julian Morris Significant discrepancies exist between national guidelines (NICE) and local Trust practices/consultant views regarding the treatment of prolonged rupture of membranes and Group …	London London Inner (South)	Department of Health and Social … National Screening Committee N.I.C.E Royal College of Obstetricians and …	2/4
3 Mar 2016	Ronald Bentley 2016-0086 · Emma Brown A previously unrecognised risk of air entering the vascular system during a cardiac procedure with conscious sedation was identified, highlighting a critical …	West Midlands Birmingham and Solihull	British Cardiac Intervention Society British Society of Interventional Radiology	1/2
3 Mar 2016	Adam Rice 2016-0085 · David Hinchliff There was poor communication between the hospital and police regarding a patient's self-discharge against medical advice, compounded by inconsistent custody care, staff …	Yorkshire and the Humber West Yorkshire (East)	St James’s University Hospital West Yorkshire Police	1/2
3 Mar 2016	Christopher Stubbs 2016-0081 · Martin Fleming The abrupt cessation of critical medication upon hospital discharge, with a follow-up GP review failing to occur, highlighted a need to improve …	Yorkshire and the Humber West Yorkshire (West)	Wibsey and Queensbury Medical Practice	0/1
2 Mar 2016	Christ Morrison 2016-0084 · Andrew Harris Concerns centred on unclear training standards and lack of medical presence during paediatric tracheostomy tube changes, with a policy for emergency transfer …	London London Inner (South)	Epsom and St Helier, University … Queen Mary’s Hospital for Children	1/2
2 Mar 2016	Curt Falk 2016-0083 · R Brittain A patient died from a viral infection (SCC) preventable by vaccination, but current policy excludes males from this vaccination, indicating a risk …	London London Inner (North)	Joint Committee on Vaccination and … Department of Health and Social …	1/2
1 Mar 2016	Peter Embra 2016-0087 · S McGovern A local authority failed to act on an urgent GP referral for a patient assessment, leading to a significant one-week delay before …	West Midlands Warwickshire	Warwickshire County Council	0/1
1 Mar 2016	Max Haigh 2016-0082 · Philip Holden Inadequate and incomplete surgical notes failed to detail a ventricular septal defect, risking future surgeons lacking vital information for subsequent operations.	Yorkshire and the Humber West Yorkshire (East)	St James’s University Hospital	0/1
29 Feb 2016	Susan George 2016-0078 · Lisa Hashmi Failures included an unreviewed discharge despite deteriorating patient condition, poor discharge coordination, inadequate record-keeping, lack of protocol for inpatient emergency calls, and …	North West Manchester (North)	Pennine Care NHS Trust Rochdale, Heywood and Middleton Clinical …	1/2
29 Feb 2016	Derrick Twiate 2016-0079 · Murray Spittal Dispensing pharmacists continue a practice, contrary to professional advice, of snipping tablets from unit dose packs into multi-dose compliance aids, risking drug …	East Midlands South Lincolnshire	Dispensing Doctors Association Royal Pharmaceutical Society	0/2
26 Feb 2016	Richard Parkes 2016-0101 · Zafar Siddique Poor GP record-keeping and a rigid policy of refusing to see late patients, even those with known complex medical histories, posed inherent …	West Midlands Black Country	Black Country Family Practice	0/1