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 259 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
19 Jan 2016	Lee Rushton Andre Rebello There is a lack of clear policy and training regarding how ACCT care plans and mandatory reviews should integrate with Cell Sharing …	North West Liverpool and Wirral	102 Petty France SW1H 9AJ The Secretary of State for …	1/3
19 Jan 2016	Irene Pearson 2016-0014 · John Pollard Matrifen patch warnings about hot baths are obscure and vague, and dangerous advice was given to use baths for patch removal. Poor …	North West Manchester (South)	Churchgate Surgery Macmillan Cancer Support Takeda UK Ltd	2/3
18 Jan 2016	Norah Fairhurst 2016-0012 · Rachael Griffin Older large goods vehicles, not mandated to have Class VI "cyclops" mirrors, have a dangerous blind spot directly in front, making pedestrians …	North West Manchester (West)	Department for Transport	1/1
15 Jan 2016	Jasmine Lapsley 2016-0022 · Nicola Jones Emergency services in rural NW Wales suffer from a lack of nighttime air support, ineffective rostering and communication for Community First Responders, …	Wales North West Wales	EMERGENCY AMBULANCE SERVICE COMMIT-TEE FOR … Welsh Ambulance Service NHS Trust Welsh Assembly Government	2/3
14 Jan 2016	Lee Rigby 2016-0011 · Alan Walsh The report identifies potential risks in resident care, including support workers not having keys for timely access, adequacy of staffing levels, review …	North West Manchester (West)	United Response	0/1
13 Jan 2016	Arenijus Nedzelskies 2016-0010 · ARW Forrest Specific synthetic cannabinoid receptor agonists (5F AKB-48, 5F PB-22) are not controlled substances, and the deceased's chronic misuse was not reported to …	East Midlands South Lincolnshire	Driver and Vehicle Licensing Agency Home Office	1/2
12 Jan 2016	Anne Scott 2016-0024 · Elizabeth Carlyon Community care providers lacked training to correctly interpret and act upon data from health monitoring devices, and county-wide safeguarding recommendations for such …	South West Cornwall	Cornwall and Isles of Scilly …	0/1
11 Jan 2016	Robin Brett 2016-0013 · Claire Balysz A missed steroid dose went unnoticed due to a lack of system alerts on both paper and electronic drug charts for patients …	South West Wiltshire and Swindon	Great Western Hospital NHS Foundation …	0/1
11 Jan 2016	Colin Williams 2016-0008 · Elizabeth Carlyon A client with complex health and social needs, exacerbated by alcoholism, experienced "agency blindness" and lacked consistent support due to fragmented services, …	South West Cornwall	Cornwall Council Local Adult Safeguarding …	0/1
11 Jan 2016	Nicholas Milligan 2016-0007 · Elizabeth Carlyon The increasing speed and power of power boat leisure craft creates additional risks that users should be aware of to prevent accidents.	South West Cornwall	British Maritime Federation Royal Yachting Association	0/2
11 Jan 2016	Emily Milligan 2016-0007-wp25057 · Elizabeth Carlyon The increased speed and power of modern power boat leisure craft introduce additional risks, requiring greater awareness from users to prevent accidents.	South West Cornwall	British Maritime Federation Royal Yachting Association	0/2
8 Jan 2016	Norman Dorn 2016-0006 · Elizabeth Carlyon Cornwall care homes may lack adequate or updated policies for recognising and confirming death and for resuscitation, with staff often lacking awareness …	South West Cornwall	Care Quality Commission Cornwall and Isles of Scilly …	0/2
8 Jan 2016	Stefen Boswell 2016-0005 · John Ellery Inconsistent police pursuit policies between local and national guidelines on wrong-way driving, coupled with inadequate communication systems for critical pursuit details, created …	West Midlands Shropshire, Telford and Wrekin	West Mercia Police	1/1
7 Jan 2016	Joanne French 2016-0004 · Elisabeth Bussey-Jones Early patient discharge was hampered by unclear assessment requirements, a failure to include family input in decision-making, and inaccurate or incomplete discharge …	South East West Sussex	Sussex Partnership NHS Trust	0/1
4 Jan 2016	Gary Peel Martin Fleming The need for deterrent measures on viaduct walls should be reviewed to prevent future deaths from individuals jumping.	Yorkshire and the Humber West Yorkshire (West)	SUSTRANS	1/1
4 Jan 2016	Mark Holdsworth 2016-0003 · Richard Marshall Police failed to communicate critical information about the deceased's recent suicide threat to arresting officers and custody staff, resulting in an incomplete …	East Midlands Central Lincolnshire	Lincolnshire Police	0/1
4 Jan 2016	Thomas Burchell 2016-0002 · Andrew Cox Inadequate and incomplete medical and nursing record-keeping, particularly a poorly maintained seizure chart, failed to accurately document a patient's critical seizure events.	South West Plymouth Torbay and South Devon	Hospital NHS Trust Derriford Hospital Borchardt Medical Centre	1/2
4 Jan 2016	Matthew Wood 2016-0001 · Andrew Harris There is no policy of reporting anything encroaching flight paths to the Heliport; the London Heliport should be a safeguarded aerodrome. The …	London London Inner South	Civil Aviation Authority Department for Transport London Heliport	2/3
4 Jan 2016	Peter Barnes 2016-0001-wp25050 · Andrew Harris Inadequate planning policies for tall buildings around the London Heliport fail to ensure safety, lacking in-depth consultation with the Heliport and official …	London London Inner South	Civil Aviation Authority Department for Transport London Heliport	2/3
31 Dec 2015	Margaret Pegnall Jacqueline Lake A GP practice had a vague domestic abuse flowchart focused on depression, lacked a specific domestic abuse questionnaire, and had no system …	East of England Norfolk	Old Catton Medical Practice	1/1