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 257 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
15 Feb 2016	Peter Tye 2016-0050 · Ian Arrow Misplacement of a central venous line into an artery highlighted a need for wider promulgation of improved insertion and removal procedures to …	South West Plymouth, Torbay and South Devon	Department of Health and Social …	1/1
15 Feb 2016	James Robertson 2016-0053 · David Horsley Carers were not required to accurately log check times, delaying understanding of events. DNACPR status was not on shift handover notes, and …	South East Portsmouth and South East Hampshire	Healthcare Management Solutions Ltd	0/1
15 Feb 2016	James Barrett 2016-0052 · David Horsley Ineffective missing persons searches were hampered by reliance on volunteer mapping systems rather than a police stand-alone system, and the lack of …	South East Portsmouth and South East Hampshire	Hampshire Constabulary Police Police Crime Commissioner for Hampshire	1/2
15 Feb 2016	Belinda Wise 2016-0049 · Lydia Brown A lift lacked signs or auditory warnings for its rear doors, which were indistinguishable from the interior, posing a significant safety risk …	East Midlands Leicester City and South Leicestershire	Health and Safety Executive Oadby and Wigston Borough Council Sainsbury’s	2/3
16 Feb 2016	Eric Gaskell 2016-0057 · Rachael Griffin Hospital policy restricts doctors to issuing only hospital-specific prescriptions. This, combined with a non-24-hour pharmacy, prevents A&E patients from accessing critical medication …	North West Manchester (West)	Royal Bolton Hospital	1/1
12 Feb 2016	Terence Brooks 2016-0056 · Peter Harrowing The hospital misinterpreted Legionella test results and lacked a clear procedure for investigating outbreaks, leading to an erroneous conclusion about the infection …	South West Avon	Bath and North East Somerset … Care Quality Commission Royal United Hospitals Bath NHS …	0/3
12 Feb 2016	Marilyn Anson 2016-0054 · Peter Harrowing Delays in urgent 'hot foot' clinic referrals, coupled with inadequate patient prioritisation and resource allocation, led to patient deterioration and death.	South West Avon	North Somerset Clinical Commissioning Group North Somerset Community Partnership Weston Area Health NHS Trust	0/3
12 Feb 2016	Sandra Wood 2016-0048 · Roger Hatch The NHS Trust's lack of routine weekend CT scan facilities led to a critical delay in an urgent scan, proving too late …	South East North West Kent	Maidstone and Tonbridge Wells NHS …	1/1
12 Feb 2016	Margaret Hions 2016-0047 · Jonathan Layton Inadequate adherence to clinical pharmacy policy regarding tinzaparin prescribing, blood level monitoring, and creatinine clearance monitoring posed risks to patient safety.	Wales Carmarthenshire and Pembrokeshire	West Wales General Hospital	1/1
12 Feb 2016	Joseph Sarkozi 2016-0055 · Peter Horrowing Fire officers prematurely concluded dust on ceiling lights caused a fire without positive evidence, highlighting a need for improved investigative practices and …	South West Avon	Avon Fire and Rescue Services Chief Fire & Rescue Adviser	1/2
11 Feb 2016	Marion Howes 2016-0046 · Veronica Hamilton-Deeley No specific concerns text was provided to summarise.	South East Brighton and Hove	Brighton and Sussex University Hospitals …	0/1
9 Feb 2016	Eitvydas Zdanys 2016-0043 · Thomas Osborne Police officers responding to a road traffic incident lacked basic life support training, rendering them unable to assess or resuscitate a seriously …	East of England Bedfordshire and Luton	Bedfordshire Police	1/1
9 Feb 2016	David Hughes 2016-0040 · Catherine Mason Critical patient observations were inconsistently performed and recorded, fluid balance charts were meaningless, patient bedrooms lacked call bells, and nursing staff showed …	East Midlands Leicestershire City and South Leicestershire	Leicestershire Partnership NHS Trust	1/1
7 Feb 2016	Christopher Broom 2016-0044 · Barrie Van den Berg Lack of adequate lighting at the harbour wall end and a single, hard-to-spot lifebelt created significant safety risks for visitors.	South West Cornwall and the Isles of Scilly	Square Sail	0/1
5 Feb 2016	Chentoori Chanthirakumar 2016-0037 · ME Hassell Communication failures, including an email rather than a face-to-face meeting about academic re-take, and mental health staff misinterpreting confidentiality, prevented effective support …	London London Inner (North)	Barts and London School of … East London NHS Trust Queen Mary University of London	0/3
5 Feb 2016	Isla Lord 2016-0035 · Thomas Osborne A critical lack of liaison between tertiary and local hospitals resulted in no agreed delivery plan for a baby with identified heart …	East of England Bedfordshire and Luton	Princess Alexandra Hospital NHS Trust	1/1
5 Feb 2016	David Mostari 2016-0034 · Thomas Osborne Urgent diagnostic tests were critically delayed over a weekend due to the hospital lacking a robust system for ensuring timely imaging, particularly …	East of England Bedfordshire and Luton	Bedford Hospital NHS Trust	1/1
5 Feb 2016	Douglas Kay 2016-0033 · Elizabeth Didcock There was significant confusion and lack of clear policy regarding transferring patients with gastrointestinal bleeding, compounded by senior staff's unawareness of new …	East Midlands Nottinghamshire	Doncaster and Bassetlaw Hospital NHS …	1/1
2 Feb 2016	Marc Poole 2016-0045 · Nicola Mundy Multiple communication failures, poorly completed observation charts, lack of a paediatric sepsis protocol, and ineffective dissemination of medical updates contributed to systemic …	Yorkshire and the Humber South Yorkshire (East)	Doncaster and Bassetlaw NHS Foundation …	1/1
2 Feb 2016	Ryan Singh Bhogal 2016-0038 · Zafar Siddique GP practice lacked continuity of care and 'Red Flag' identification for a child with prolonged illness, while the hospital failed to adequately …	West Midlands Black Country	Lockfield Surgery New Cross Hospital	1/2