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 258 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
5 Feb 2016	Samantha MacDonald 2016-0036 · Jennifer Leeming A broken window restrictor in student accommodation, despite meeting standards, allowed a fatal fall, highlighting the need for robust risk assessments and …	North West Manchester (West)	Campus Living Villages Department for Education	2/2
2 Feb 2016	Michael Valentine 2016-0032 · Andrew Cox Inadequate communication and administrative procedures led to a GP not being informed about the rejection of an urgent mental health assessment, as …	South West Plymouth, Torbay and South Devon	Knowle House Surgery Livewell South West, Mount Gould …	2/2
2 Feb 2016	Lee Hoyle 2016-0030 · Jacqueline Lake Regulations that would prevent take-off in limited visibility conditions do not apply to departures from non-commercial ventures and unlicensed aerodromes; the coroner …	East of England Norfolk	Civil Aviation Authority	1/1
2 Feb 2016	Edward Haughey 2016-0030-wp25087 · Jacqueline Lake Regulations that would prevent take-off in limited visibility conditions do not apply to departures from non-commercial ventures and unlicensed aerodromes; the coroner …	East of England Norfolk	Civil Aviation Authority	1/1
2 Feb 2016	Carl Dickerson 2016-0030-wp25086 · Jacqueline Lake Regulatory loopholes allow non-commercial flights from unlicensed aerodromes to operate in conditions prohibited for commercial ventures, despite previous accidents and unimplemented recommendations …	East of England Norfolk	Civil Aviation Authority	1/1
1 Feb 2016	Lorraine Youngs 2016-0029 · David Osborne A vulnerable service user's agreed care package was not implemented or followed up, as there was no system in place to track …	East of England Norfolk	Norfolk County Council- Adult Social …	1/1
29 Jan 2016	Louise Locke 2016-0026 · Grahame Short Premature discharge from mental health services occurred without adequate risk assessment or support, compounded by a lack of systems to collate multi-agency …	South East Central Hampshire	Southern Health NHS Foundation Trust	1/1
28 Jan 2016	Ronald Volante 2016-0499 · Andre Rebello Call handlers failed to use medical history to inform ambulance services and were not trained to report changes in patient presentation, indicating …	North West Liverpool	Magenta Living Support Link	1/1
28 Jan 2016	Antony Briggs 2016-0028 · John Pollard Incompatible hospital IT systems prevented urologists from accessing patient test results, leading to a dangerous gap in follow-up when local GPs failed …	North West Manchester (South)	Stockport NHS Foundation Trust	1/1
28 Jan 2016	Andrew Coates 2016-0025 · David Roberts An unsuitable wooden shed was licensed for fireworks storage, containing other combustibles and having deficient licensing that failed to specify types or …	North West Cumbria	Cumbria County Council	1/1
27 Jan 2016	Joanna Bowring 2016-0027 · Patricia Harding Carers were excluded from risk assessment processes and not advised on suicide risk behaviours, while the patient left an initial assessment without …	South East Mid Kent and Medway	Kent and Medway NHS and …	1/1
26 Jan 2016	Rio Andrew 2016-026 · Selena Lynch The regulation of private medical companies at events is inadequate, creating false security and leaving event medical provision, including "ambulance technicians," largely …	London London (South)	Department of Health and Social … Lifeskills	2/2
22 Jan 2016	Javaid Iqbal 2016-0023 · Kevin McLoughlin Charcoal packaging warnings about indoor use lack prominence and do not explicitly highlight the risk of death from carbon monoxide poisoning.	North West Manchester (West)	Tesco Store PLC	0/1
22 Jan 2016	Darren Wakefield 2016-0020 · Ian Arrow The report highlights a national safety issue and requests confirmation that IPCC recommendations have been followed, implying a potential gap in implementing …	South West Plymouth, Torbay and South Devon	National Police Chiefs’ Council	1/1
21 Jan 2016	Elvis Snelson 2016-0042 · Fiona Borrill The "legal high" acetylfentanyl, a highly potent opioid, poses significant risks due to users being unaware of its opioid nature, leading to …	North West Manchester City	Department of Health and Social …	0/1
21 Jan 2016	Alice Dickenson 2016-0021 · Helen Redman The GP referral form for rapid access endoscopy is limited, potentially leading to the omission of critical past medical history that would …	South East Central and South East Kent	Kent and Medway Cancer Collaborative	0/1
21 Jan 2016	Leslie Murray 2016-0016 · Fiona Wilcox Insufficient staffing on hospital wards prevents essential one-to-one patient care, leading to preventable falls and other critical care deficiencies that may contribute …	London London Inner (West)	St George’s Hospital	0/1
20 Jan 2016	Leslie Summerfield 2016-0019 · John Pollard The withdrawal of urgent endoscopy services at a hospital, despite available resources, forces critically ill patients to be transported, causing unnecessary discomfort …	North West Manchester (South)	Central Manchester NHS Trust	0/1
20 Jan 2016	Derek Hare 2016-0018 · John Pollard The use of two separate patient note systems caused confusion and errors, and repeated denials of hospital appointments led to a significantly …	North West Manchester (South)	Tameside Hospital NHS Trust	1/1
20 Jan 2016	Steven Rogers 2016-0017 · John Pollard A doctor discharged a patient without seeing them, indicating a fundamental lack of understanding of discharge importance, and staff erroneously omitted long-acting …	North West Manchester (South)	Stockport NHS Foundation Trust	1/1