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 256 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
26 Feb 2016	Devinder Seth 2016-0075 · Nadia Persaud Ward staff lacked clear guidance on recognising and managing the risks and side effects of opiate medication in orthogeriatric patients, leading to …	London London (East)	Royal London Hospital	1/1
26 Feb 2016	Jakovas Fofonovas 2016-0077 · Andrew Harris Safety recommendations from a British Transport Police report to restrict public access and enhance safety at a railway bridge remained unaddressed by …	London London Inner (South)	Network Rail	1/1
25 Feb 2016	Amy Cooper 2016-0072 · Andre Rebello Commissioned maternity services lacked compatible, digitally available record-keeping and scan systems, leading to inefficient paper-note transfers and hindering seamless patient care and …	North West Liverpool and Wirral	Department for Health NHS England	0/2
25 Feb 2016	David Palmer 2016-0076 · M Spittal Unlicensed firearms are often insecurely stored, available for impulsive use. Publicising that surrendering such weapons usually avoids prosecution might encourage their removal.	East Midlands South Lincolnshire	Lincolnshire Police	0/1
25 Feb 2016	Betty Addison 2016-0071 · Rachael Griffin A patient at a care home received five additional, unprescribed Dalteparin injections, with no clear explanation for their source or why they …	North West Manchester (West)	Cuerden care Homes	0/1
24 Feb 2016	Marie Rollason 2016-0100 · Zafar Siddique The report identifies a potential lack of recognition of the deceased's repeated loss of consciousness prior to hospital readmission.	West Midlands Black Country	Royal Wolverhampton, New Cross Hospital	1/1
24 Feb 2016	Wilfred Pearson 2016-0088 · John Pollard Concerns include outdated treatment protocols, poor medical notes, inadequate care escalation, and severe junior medical staff shortages. The patient was also unlawfully …	North West Manchester (South)	Tameside Hospital NHS Foundation Trust	1/1
23 Feb 2016	Freda Weston 2016-0080 · John Pollard Premature discharge, critical delays in antibiotic administration due to severe staff shortages, and staff unfamiliarity with escalation guidelines were identified. Handover sheets …	North West Manchester (South)	Stockport NHS Foundation Trust	1/1
23 Feb 2016	Lisa Day 2016-0070 · ME Hassell The 111 service failed to discuss alternative hospital transport with the patient's friend and did not explain the severe risks of a …	London London Inner (North)	London Ambulance Services NHS Trust London Central & West Unscheduled … St Charles Hospital	2/3
23 Feb 2016	Edith Kirkham 2016-0068 · John Pollard Intermediate care suffered from unclear management standards, inadequate staffing, staff failing to understand notes, and a lack of proper handover from the …	North West Manchester (South)	L and M Healthcare Tameside Hospital NHS Trust	1/2
22 Feb 2016	Patricia Medland 2016-0102 · Lydia Brown The patient's daughter was unaware of her designated role as a protective factor in the care plan, potentially preventing her from recognising …	South West Exeter and Greater Devon	Bampton Surgery	1/1
22 Feb 2016	Clifford Crofts 2016-0066 · Caroline Topping A critical post-operative care plan went missing, and nursing staff faced unsuccessful attempts to escalate care for acute pain. Significant delays occurred …	South East Surrey	Ashford and St Peter’s Hospital …	1/1
19 Feb 2016	Geoffrey Moyse 2016-0067 · Veronica Hamilton-Deeley The report raises concerns that were not detailed in the excerpt.	South East Brighton and Hove	Brighton and Hove Clinical Commissioning … Brighton and Hove Integrated Care … Brighton and Sussex University Hospital …	2/3
19 Feb 2016	Brenda Morris 2016-0065 · ME Hassell Lack of communication with the partner regarding leave conditions and no routine family feedback were identified. There was also confusion about doctor …	London London Inner (North)	East London NHS Foundation Trust	1/1
18 Feb 2016	Euphemia Aldred 2016-0062 · Michael Singleton The report raises concerns that were not detailed in the excerpt.	North West Blackburn, Hyndburn and Ribble Valley	East Lancashire Healthcare NHS Trust	0/1
17 Feb 2016	Vanessa Dadswell 2016-0060 · Simon Wickens Mental health services lacked an intermediate referral option between 4-hour A&E assessment and 5-day appointments, preventing timely intervention for patients requiring urgent …	South East Surrey	Sussex Partnership NHS Foundation Trust West Sussex County Council	1/2
17 Feb 2016	Matthew Crowley 2016-0063 · Patricia Harding A&E delays due to short-staffing prevented timely triage and immediate senior doctor review. There was a delay in patient ownership, decision-making, and …	South East Mid Kent and Medway	Maidstone and Tunbridge Wells NHS …	0/1
16 Feb 2016	Philip Denning 2016-0058 · Heidi Connor Fragmented services for patients with co-occurring substance misuse and mental health issues, a lack of information sharing, and primary care's misunderstanding of …	East Midlands Nottinghamshire	Framework CRI NHS England Nottinghamshire healthcare NHS Foundation Trust	0/4
15 Feb 2016	Adam Withers 2016-0059 · Alison Hewitt Psychiatric nursing staff failed to sufficiently record patient observations and interactions, lacking understanding of their importance, and made unlabelled retrospective entries after …	South East Surrey	Department of Health and Social … NHS England Surrey and Borders Partnership NHS …	3/3
15 Feb 2016	Eileen Thompson 2016-0051 · David Clark A specific bed design flaw allows inner wheels to remain unlocked when the bed is placed against a wall, creating a risk …	West Midlands Warwickshire	George Eliot Hospital NHS Trust NHS England Welsh Government	2/3