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 262 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
16 Nov 2015	Nadine Brookes-Walker 2015-0463 · Elaine Moloney Packaging for Fentanyl patches may not adequately convey the severe risks associated with using damaged patches, potentially leading to patient misuse.	North West Manchester (North)	Teva UK Ltd	1/1
16 Nov 2015	Christine McNamara 2015-0436 · Patricia Harding There is a lack of clear pathways for post-ERCP patients with complications, and out-of-hours radiography is hampered by the absence of a …	South East Mid Kent and Medway	Maidstone and Tunbridge Wells NHS …	1/1
16 Nov 2015	Emma Bray 2015-0438 · Laura Johnson The report identifies failures to obtain a proper medication history, refer the deceased to a psychiatrist, follow up with the deceased, and …	London London (East)	Policy and Patient Safety Directorate	1/1
13 Nov 2015	Irene Scholey 2015-0462 · Melanie Williamson No specific concerns were detailed in the provided text, which instead referred to an external narrative conclusion.	Yorkshire and the Humber West Yorkshire (East)	Wakefield MDC Wakefield District Safeguarding Adults Board	0/2
12 Nov 2015	Matthew Groom 2015-0503 · ME Hassell Significant delays occurred in mental health assessment and prescribed medication administration. Staff failed to plan for patient elopement, did not involve hospital …	London London Inner (North)	Camden & Islington NHS Trust Whittington Hospital NHS Trust	2/2
12 Nov 2015	Christopher Connor 2015-0461 · Andrew Barkley Ambulance response was delayed, only arriving after police expedited the call, indicating potential issues with emergency service dispatch or prioritization.	Wales Powys, Bridgend and Glamorgan Valleys	Welsh Ambulance Trust	1/1
12 Nov 2015	Guy Robinson 2015-0432 · Lisa Hashmi The 'AWOL' protocol was improperly applied due to staff unfamiliarity, lacking Trust-wide implementation. A significant service gap exists with no inpatient clinical …	North West Manchester (North)	Pennine Care NHS Trust	1/1
11 Nov 2015	David White 2015-0437 · Jacqueline Devonish Critical medication side effects causing confusion were unrecorded and unaddressed. Despite documented fall risks in nursing notes, adequate supervision was absent, and …	London London Inner (North)	Barts Health NHS Trust	1/1
11 Nov 2015	Alexander Hadley 2015-0433 · D Pritchard Jones The absence of warning signs at a public waterfall meant people were unaware of dangerous currents, creating a risk of further accidental …	Wales North West Wales	Gwynedd Council	1/1
9 Nov 2015	John Moreton 2015-0430 · Anthony Curzon A pedestrian stile leads directly onto a busy dual carriageway with a national speed limit, and there are no warning signs for …	West Midlands Stoke-on-Trent and North Staffordshire	Highways Agency	0/1
6 Nov 2015	Vera Williams 2015-0428 · Nicola Jones Emergency Department doctors and staff lack a digital system to support their work.	Wales North East and North Central Wales	Betsi Cadwaladr University NHS Trust	0/1
6 Nov 2015	Brian Shillinglaw 2015-0427 · Veronica Hamilton-Deeley The provided text is incomplete and does not contain specific concerns.	South East Brighton and Hove	Brighton and Sussex University Hospitals … Care Quality Commission NHS England Clinical Commissioning Group	0/8
6 Nov 2015	Carl Hughes 2015-0429 · Michael Singleton Motorcross events do not mandate body protection for competitors, which could prevent fatal injuries.	North West Blackburn, Hyndburn & Ribble Valley	Motor Cross Federation	1/1
4 Nov 2015	Michael Logue 2015-0426 · Louise Hunt A general practitioner failed to conduct a physical examination during a home visit for a post-surgery patient complaining of pain and ill …	West Midlands Birmingham and Solihull	Central Surgery	1/1
3 Nov 2015	David Pooley 2015-0421 · Caroline Beasley-Murray A named nurse was not allocated until the day before death, breaching trust policy and resulting in a failure to carry out …	East of England Essex	South Essex Mental Health Partnership … Lancashire Care NHS Trust	1/2
3 Nov 2015	Peter Buckle 2015-0425 · Jacqueline Lake An unsafe work method was adopted without a risk assessment, and a strong health and safety culture was absent among employees despite …	East of England Norfolk	Wayland Farms Limited	1/1
2 Nov 2015	Richard Green 2015-0456 · David Roberts Prison medical professionals failed to act on recorded self-harm history in SystmOne due to system usability issues, workload pressure, and a lack …	North West Cumbria	Ministry of Justice National Offender Management Service	1/2
2 Nov 2015	Marie Quinn 2015-0423 · Rachael Griffin Sub-optimal DVT prophylaxis, including delayed medication and missing mechanical treatment, was provided. Incorrect discharge instructions led to early cessation, and the nursing …	North West Manchester (West)	HC-One Limited Richmond House Nursing Home	0/2
2 Nov 2015	Steven Jackson 2015-0422 · Caroline Beasley-Murray A paramedic failed to effectively use the sepsis screening tool, indicating a need for better training for ambulance staff on its use …	East of England Essex	Bevan Brittan Law Firm East of England Ambulance Service … General Medical Council Irwin Mitchell Solicitors	0/6
2 Nov 2015	Jacqueline Williams 2015-0421-wp25020 · Michael Singleton The mental health referral system was prone to human error, failing to provide ED staff with confirmation of accepted referrals or assessment …	North West Blackburn, Hyndburn and Ribble Valley	East Lancashire NHS Trust	1/1