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 263 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
2 Nov 2015	Jean Gillespie 2015-0419 · Alan Wilson Senior care staff lacked awareness of a resident's life-threatening condition and medication, failing to appreciate the urgency of re-ordering supplies. Care home …	North West Blackpool and Fylde	Alexandra Court Care Home	1/1
2 Nov 2015	Connor Sparrowhawk 2015-0445 · Darren Salter The bath time observation policy for epileptic patients is inadequate, with concerns about the effectiveness of sound-only monitoring and potential staff distraction. …	South East Oxfordshire	CQC Southern Health NHS Foundation Trust	1/2
30 Oct 2015	Dennis Stark 2015-0420 · Alan Wilson A rehabilitation unit's lack of a lift significantly delayed the emergency removal of an obese patient from a second-floor room, posing a …	North West Blackpool and Fylde	Newton House (formerly Regency Hospital)	0/1
30 Oct 2015	Mary Bloom 2015-0417 · Nadia Persaud Trust policy on heparin administration was not followed, including failure to weigh the patient, consult haematology, or take post-hydration bloods. Critical dosage …	London East London	Barking, Havering and Redbridge University …	1/1
29 Oct 2015	Hilda Haughton 2015-0460 · John Pollard Patient falls resulted from unraised cot sides and were compounded by a lack of hospital staff candour. Concerns were also raised regarding …	North West Manchester (South)	Secretary of State for Health Tameside Hospital NHS Foundation Trust	2/2
29 Oct 2015	Tamara Mills 2015-0416 · Terence Carney Concerns were raised that the child's asthma care focused only on acute presentations, failing to address the underlying chronic condition holistically across …	North East Gateshead & South Tyneside	Farnham Medical Centre Health Education England National Institute for Health and … Newcastle & Gateshead Clinical Commissioning …	0/9
29 Oct 2015	Florence Lowe 2015-0415 · Anthony Curzon A 60mph speed limit on a road with residential properties and busy amenities is inappropriate, and a major roundabout lacks a pedestrian …	West Midlands Stoke-on-Trent & North Staffordshire	Staffordshire County Council	0/1
28 Oct 2015	Kevin Forster 2015-0453 · Andrew Tweddle HMP Durham had a serious drug problem, but staff lacked awareness and training on overdose policies, leading to complacent responses, inadequate treatment …	North East County Durham and Darlington	G4S National Offender Management Service	2/2
28 Oct 2015	Christopher Smith 2015-0455 · Simon Jones A 12-minute ambulance call delay resulted from communication breakdown between police control rooms regarding responsibility. A clear procedure is required to prevent …	North West Manchester (West)	Greater Manchester Police	0/1
27 Oct 2015	Bartosz Bortniczak 2015-0452 · Nicola Mundy The 40mph speed restriction is placed after a dangerous road bend, rather than before it, despite multiple incidents, unnecessarily increasing the risk …	Yorkshire and the Humber South Yorkshire (East)	Doncaster Highways Services	1/1
27 Oct 2015	George Hines 2015-0448 · Peter Harrowing Defects in the pull-cord alarm system were unaddressed, residents were responsible for smoke detector maintenance, and smoke detectors were not linked to …	South West Avon	Bristol City Council	0/1
27 Oct 2015	Scarlett Jukes 2015-0449 · Peter Harrowing Neither public participants nor paid hunt staff are required to wear protective headgear that complies with recognised safety standards during hunting events, …	South West Avon	Foxhound Association Health and Safety Executive	1/2
27 Oct 2015	Charlotte Bevan and Zaani Malbrouck 2015-0418 · Maria Voisin There was no mandatory multi-disciplinary team meeting or widely circulated care plan for pregnant women with known mental health conditions, risking fragmented …	South West Avon	Avon and Wiltshire Mental Health …	1/1
26 Oct 2015	Allan Beasley Louise Hunt Care home staff were unaware of the falls prevention policy, leading to inaccurate recording, delayed escalation of falls, and unreliable patient observation …	West Midlands Birmingham and Solihull	Sunrise care home	0/1
26 Oct 2015	Neil Garry 2015-0446-wp25121 · Melanie Williamson A busy road frequently used by pedestrians, including children, lacks a pedestrian crossing, posing a significant safety risk.	Yorkshire and the Humber West Yorkshire (East)	Highways England	1/1
26 Oct 2015	Carl Foot 2015-0447 · ME Hassell Delayed prison cell bell responses, lack of a system to track bell activation times, and inadequate post-incident review contributed to a prisoner's …	London London Inner (North)	HMP Pentonville	0/1
26 Oct 2015	Barry Thraves 2015-0443 · Lydia Brown Significant delays in psychiatric follow-up, lack of community support, and poor communication between mental health teams and GPs led to unaddressed patient …	East Midlands Leicester City and South Leicestershire	Leicester Partnership NHS Trust Leicester City Council	2/2
26 Oct 2015	Wayne O’Neill 2015-0444 · Andrew Cox There was inadequate recognition of drug contraindications and dangerous psychotropic medication combinations, with no routine ECG monitoring performed despite expert recommendations, leading …	West Midlands Worcestershire	Worcestershire Health and Care NHS …	1/1
23 Oct 2015	Margaret Ferry 2015-0450 · Karin Welsh The absence of a formal policy and poor communication between two NHS Trusts resulted in unclear responsibilities and misunderstandings during patient referrals.	North East Sunderland	City Hospitals Sunderland NHS Foundation …	1/1
23 Oct 2015	Samuel Gale 2015-0454 · John Sleightholme A prisoner's ACCT plan was closed without consulting crucial healthcare and management staff, suggesting a critical lapse in multi-disciplinary oversight for vulnerable …	Yorkshire and the Humber South Yorkshire (East)	HMP and YOI Doncaster	2/1