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 260 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
30 Dec 2015	Mollie Bentham Alan Walsh Repeated family concerns about abdominal pain and rising infection markers were not documented, escalated to medical teams, or examined, leading to a …	North West Manchester (West)	Royal Bolton Hospital NHS Foundation …	1/1
29 Dec 2015	Imran Douglas 2015-0446 · Andrew Harris A more flexible, person-based system may be safer than the current rule-based system regarding the transition of duties from YOT/YJB to PMU …	London London Inner (South)	General Medical Council London Borough of Tower Hamlets HM Prison and Probation Service	1/3
24 Dec 2015	Christopher Higgins 2015-0480 · Jacqueline Lake Inconsistent mental health observation practices, inadequate patient escort protocols during police transfers, unassessed safety risks in the environment, and poor inter-agency agreements …	East of England Norfolk	James Paget University Hospitals NHS … Norfolk and Norwich University Hospitals … Norfolk and Suffolk NHS Foundation … Queen Elizabeth Hospital	3/4
24 Dec 2015	Angela Brealey 2015-0473 · Andrew Haigh The trust lacked clear procedures for handling third-party information, showed minimal multidisciplinary team involvement in patient care, and its serious incident review …	West Midlands Staffordshire (South)	South Staffordshire and Shropshire NHS … St George’s Hospital	1/2
22 Dec 2015	Shalini Ganesh-Ram 2016-0117 · ME Hassell The report identifies that a raised pulse, abdominal pain and lack of urine output did not prompt a CT scan and a …	London London Inner (North)	Barts Health NHS Trust	0/1
21 Dec 2015	Kay Sheard John Gittins Pulse oximeter alarm settings are fixed at a routine level rather than being adjusted to individual patient baselines, risking unnoticed significant oxygen …	Wales North Wales (East and Central)	BCUHB, Ysbyty Gwynedd	1/1
21 Dec 2015	Mary Hollands Nicola Jones The system for providing radiologist reports to the Emergency Department is unreliable, creating a risk that subtle injuries may be missed and …	Wales North Wales (East and Central)	BCUHB, Ysbyty Gwynedd	1/1
17 Dec 2015	James Graham Andrew Tweddle Critical communication failures between primary care and podiatry, coupled with a lack of ownership in referral processes and administrative errors, caused significant …	North East County Durham	G4S Medical Services Premier Physical Healthcare Spectrum Community Health CIC	1/3
17 Dec 2015	Edna Cleaton Lousie Hunt The practice lacked systems for regular medical reviews of patients on citalopram, resulting in a three-year delay in review and a missed …	West Midlands Birmingham and Solihull	Jockey Road Medical Centre	1/1
16 Dec 2015	William Driscoll Emma Whitting There are serious deficiencies in the medical assessment process for drivers, including insufficient investigation of health conditions, leading to inadequately assessed individuals …	West Midlands Birmingham and Solihull	The Driver and Vehicle Licensing …	0/1
15 Dec 2015	Joyce Tozer Emma Brown Omnipaque is frequently administered at doses exceeding manufacturer's guidelines, sometimes via central lines, which exposes interventional radiology patients to potential toxicity risks.	West Midlands Birmingham and Solihull	University Hospitals Birmingham NHS Foundation …	1/1
10 Dec 2015	Ololade Olaobaju Philip Barlow There is no joint guidance for "Can't Intubate Can't Oxygenate" situations when both anaesthetists and ENT surgeons are present, leading to inconsistent …	London London Inner (South)	ENT UK Royal College Anaesthetists	1/2
15 Dec 2015	Ruth Smith Mary Burke There were significant delays in doctor review, inadequate nursing observations, and poor record-keeping by both nursing and medical staff. Crucial follow-up for …	Yorkshire and the Humber West Yorkshire (West)	Calderdale and Huddersfield NHS Foundation …	1/1
15 Dec 2015	Kamrul Rubel Louise Hunt The gym did not enforce the use of the emergency stop cord despite providing advice, raising concerns about adherence to safety protocols …	West Midlands Birmingham and Solihull	Birmingham City Council	0/1
15 Dec 2015	Derek Thomas 2015-0502 · Crispin Oliver Prison reception procedures failed under extreme pressure, leading to suicide risk information being overlooked due to staffing issues. Additionally, there was poor …	North East County Durham and Darlington	CARE UK G4S GEOAmey HMP Durham	4/5
14 Dec 2015	Julie Rose Chris Morris The "Unable to Make Contact Protocol" lacks clarity on mandatory police welfare checks for high-risk patients, and staff demonstrated inadequate understanding of …	South East Kent (Central and South East)	Kent and Medway NHS and …	0/1
14 Dec 2015	Kevin Gilbert Rachel Redman There was confusion and unreasonable delay in transferring an acute aortic dissection patient to a tertiary center, including a failure to escalate …	South East Kent (Central and South East)	St Thomas' Hospital	1/1
14 Dec 2015	Alan Walker John Gittins Critical information was not consistently recorded in nursing notes, and handovers did not reference these records, risking significant patient details being missed …	Wales North Wales (East and Central)	BCUHB, Ysbyty Gwynedd	1/1
14 Dec 2015	Daniel Byrne Thomas Osborne There were repeated failures to identify and assess suicide risk in newly arrived prisoners, with nursing staff notably absent from initial health …	South East Milton Keynes	Ms Claire Murdoch, Chief Executive, … Northwest London NHS Trust	2/2
14 Dec 2015	Paul Whitehead Kevin McLoughlin Emergency response procedures were inefficient, with delays in contacting emergency services, inadequate first aid provision, and difficulties for paramedics locating the casualty …	Yorkshire and the Humber West Yorkshire (East)	WE Rawson Ltd, Castle Bank …	1/1