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.

Response tracker Organisations Advanced search

Keyword

Browse by year

Browse by region

Sort

Reports

6,383 reports · Page 261 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
14 Dec 2015	William Maskell Elizabeth Earland The absence of clear protocols and an overemphasis on student autonomy led to delayed intervention and reluctance to force entry for a …	South West Exeter and Greater Devon	Devon Partnership NHS Trust Students Union, University of Exeter University of Exeter	2/3
11 Dec 2015	Margaret O’Brien Chinyere Inyama Staff lacked specific, prescribed training on how to properly conduct and record observations of residents.	London London (West)	CARE UK	1/1
9 Dec 2015	Jake Robinson 2015-0474 · Joanne Kearsley The provided concerns text is incomplete, preventing a proper summary of the identified safety issues.	North West Manchester (South)	Bodmin Road Health Centre Greater Manchester NHS Area Team Greater Manchester West Health NHS …	3/3
8 Dec 2015	Madhumita Mandal Selena Lynch An emergency department streaming model that relied on untrained receptionists without medical observations led to critical delays in patient assessment by qualified …	London London (South)	Croydon Clinical Commissioning Group Croydon Health Services Virgin Care Wandle LLP	3/3
4 Dec 2015	Elsie Brown Stephanie Haskey Absent falls/bed rails assessments, incomplete care plans, poor record-keeping, inadequate night staffing, and informal handovers created significant safety risks due to unclear …	East Midlands Nottinghamshire	Your Health Ltd	1/1
3 Dec 2015	Codrut Iederan ME Hassell The construction site had inadequate first aid provision, with the designated first aider off-site and non-English speaking workers untrained and unaware of …	London London Inner (North)	Zelltec Limited	0/1
n/a	Laura Newlands John Gittins Incomplete safety plans, missed professional meetings, and an unreviewed case closure by Children's Social Services left a vulnerable young person without adequate …	Wales North Wales (East and Central)	Denbighshire County Council	0/1
1 Dec 2015	Ricky Hudson Emma Brown Quad bike riders on public roads are not required to wear crash helmets or possess additional driving qualifications, posing significant safety risks …	West Midlands Birmingham and Solihull	Department for Transport Driver and Vehicle Licensing Agency Driver and Vehicle Standards Agency	1/3
1 Dec 2015	Bryan Catanach Andrew Cox Significant communication failures between clinicians and staff led to delays in patient transfer, senior review, and confusion over care instructions. Additionally, inadequate …	West Midlands Worcestershire	Royal Orthopaedic Hospital	1/1
30 Nov 2015	Stephen Adams Geraint Williams Mental Health Liaison Team risk assessment forms are inadequately completed, with the suicide risk box frequently left blank. This leads to crucial …	West Midlands Worcestershire	Worcestershire Health and Care NHS …	0/1
27 Nov 2015	Thelma Clarkson David Horsley The NICE Head Injury Pathway fails to include Clopidogrel as a trigger for CT scans, unlike Warfarin, despite its known bleeding risk. …	South East Portsmouth and South East Hampshire	National Institute for Health and …	0/1
27 Nov 2015	Darren Jones Heidi Connor The report identifies a need for review of protocols regarding when renal advice should be sought, especially for transplant patients, along with …	East Midlands Nottinghamshire	Burton Hospitals NHS Foundation Trust	0/1
26 Nov 2015	Robert Mansfield Jonathan Layton Three deaths at the Millpond indicate significant safety concerns, highlighting the need for fencing, improved lighting, clear warning notices, and readily available …	Wales Carmarthenshire and Pembrokeshire	Pembrokeshire County Council	0/1
25 Nov 2015	Dean Boland 2015-0486 · Louise Hunt Pervasive drug issues in the prison are exacerbated by a lack of officer awareness, poor multi-disciplinary communication, and insufficient drug administration checks. …	West Midlands Birmingham and Solihull	Birmingham Community Healthcare NHS Trust Birmingham Prison National Offender Management Service	1/3
25 Nov 2015	Thomas Collins 2015-0469 · John Pollard The attending paramedic lacked confidence in making a clinical decision and inappropriately deferred to an out-of-hours service, indicating a potential training or …	North West Manchester (South)	Haughton Thornley Medical Centres North West Ambulance Service	2/2
24 Nov 2015	Piotr Kucharz 2015-0465 · Alan Wilson Mental health staff displayed a critical lack of consistency and clarity on what constitutes an effective patient observation, with some failing to …	North West Blackpool and Fylde	Lancashire Care NHS Foundation Trust	1/1
24 Nov 2015	Jonathan Hawes 2015-0466 · Caroline Sumeray The 60 mph speed limit on Cowleaze Hill is unsafe due to blind bends and cambers. There is a critical need to …	South East Isle of Wight	Islands Roads	1/1
24 Nov 2015	Thomas Black 2015-0467 · Wendy James Prison staff failed to seek timely medical advice for a clearly unwell prisoner, indicating a critical lapse in duty of care and …	Wales Gwent	HMP Usk	0/1
23 Nov 2015	Alan Ludlow 2015-0470 · Allison Summers Critical information about residents' past incidents and risks is not adequately exchanged between care providers during placement. This leads to new homes …	South East Mid Kent and Medway	Kent County Council	0/1
17 Nov 2015	Frank Mellers 2015-0464 · Zafar Siddique The report identifies that the patient's DNAR status was fixed without family consultation, poor communication between staff led to resuscitation attempts despite …	West Midlands Black Country	Care Quality Commission (CQC) Walsall Manor Hospital	1/2