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 264 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
23 Oct 2015	Hireiti Kuflesion 2015-0414 · Emma Brown Pregnant women with mechanical heart valves received insufficient Clexane dosing and monitoring, combined with clinicians' lack of understanding of thrombosis risks, resulting …	West Midlands Birmingham and Solihull	Birmingham Women’s NHS Trust British Cardiovascular Society N.I.C.E Royal College of Obstetricians and …	0/6
22 Oct 2015	Richard Laco 2015-0411 · ME Hassell Critical construction method variations were undocumented in safety plans, and key personnel lacked understanding of procedures, leading to significant workplace safety risks.	London London Inner (North)	CMF Limited Laing O’Rourke UK & Europe	2/2
22 Oct 2015	Glenda Day 2015-0410 · Heidi Connor A doctor granted home leave without reviewing the patient or updating risk assessments, exposing a lack of clear written policies and consistent, …	East Midlands Nottinghamshire	Nottinghamshire Healthcare NHS Trust	0/1
22 Oct 2015	Harry Mellor 2015-0409 · Maria Mulrennan There is no reliable system to track child GP de-registration, creating significant safeguarding risks, especially for children with chronic health needs, as …	East Midlands Nottinghamshire	Department of Health and Social … General Medical Council Nottingham City Clinical Commissioning Group Nottinghamshire Safeguarding Children Board	4/5
22 Oct 2015	Diane Knight 2015-0408 · John Tomalin The practice of placing towels over doors on the unit obstructed staff monitoring and could conceal self-harm attempts, requiring alternative patient privacy …	South West Exeter and Greater Devon	Devon Partnership Trust	1/1
21 Oct 2015	David Baddeley 2015-0451 · Joanne Kearsley Incompatible electronic records, poor communication between practices, and delayed record reviews led to critical mental health diagnoses and medication needs being repeatedly …	North West Manchester (South)	Greater Manchester NHS Area Team	1/1
21 Oct 2015	Samantha Beach 2015-0413 · Katy Skerrett The report identifies a lack of appropriate escalation to senior colleagues, no process for sharing information between community midwives, GPs, and the …	South West Gloucestershire	Gloucestershire Hospitals NHS Trust	0/1
21 Oct 2015	Dorothy Cooper 2015-0412 · Nicola Mundy Inadequate information transfer during inter-hospital referrals and the receiving team's failure to proactively address missing clinical data risked incorrect diagnoses and treatment …	Yorkshire and the Humber South Yorkshire (East)	Leeds Teaching Hospitals NHS Trust Mid Yorkshire NHS Trust	2/2
20 Oct 2015	Erich Speilmann 2015-0389 · Caroline Beasley-Murray The quality of street lighting at the incident location was poor and may have contributed to the event.	East of England Essex	Essex Highways Agency	0/1
20 Oct 2015	William Abel 2015-0406 · Lydia Brown Failure to conduct a Mental Health Act assessment and inadequate communication with family regarding the patient's suicidal intentions and mental health relapse …	East Midlands Leicester City and Leicestershire South	Leicester Partnership NHS Trust	1/1
19 Oct 2015	Kyle Hull 2015-0379 · Andrew Tweddle Inadequate CCTV coverage and monitoring may fail to detect risks of self-harm, property damage, or identify dangerous areas like fragile roofs, hindering …	North East County Durham and Darlington	Darlington Cattle Mart	1/1
19 Oct 2015	Vasilis Ktorakis 2015-0377 · ME Hassell The report identifies errors in care, including a delay in starting Syntocinon, inadequate recording of a management plan, an error of judgement …	London London Inner (North)	Whittington Hospital NHS Trust	1/1
16 Oct 2015	Caroline Robey 2015-0376 · Lydia Brown Community healthcare providers failed to use a sepsis screening tool or adopt the national sepsis clinical toolkit, leading to missed diagnosis opportunities …	East Midlands Leicester City and Leicestershire South	West Leicester CCG East Midlands Ambulance Service NHS England Loughborough, Leicestershire	2/4
16 Oct 2015	Adrian Smith 2015-0378 · Louise Hunt A clear instruction for an MRI scan from a specialist hospital was not followed by staff at another hospital, highlighting a lack …	West Midlands Birmingham and Solihull	Heart of England NHS Foundation … NHS England	1/2
15 Oct 2015	William Tolen 2015-0407 · John Pollard Significant failures in care home note-keeping, staff training, and communication led to delayed essential care. Procedures were performed unsafely and without adequate …	North West Manchester (South)	Shawe Lodge	1/1
14 Oct 2015	Alan Tear 2015-0373 · Lydia Brown Post-operative instructions were not followed, and rising EWS observations were not reported to medical staff. Communication between interventional radiology and nursing teams …	East Midlands Leicester City and Leicestershire South	University Hospitals of Leicester NHS …	1/1
13 Oct 2015	Nathaniel Phillips 2015-0375 · Joanne Kearsley Brittle asthma, a life-threatening condition, is not covered by medical exemption certificates, causing patients to miss medication due to cost and preventing …	North West Manchester (South)	Department of Health and Social …	1/1
13 Oct 2015	Catherine Findlay 2015-0372 · Simon Jones Concerns about the availability and misuse of dangerous "research chemicals" like MXP, which are freely marketed online, consumed, and pose a life-threatening …	North West Manchester (West)	Advisory Council on the Misuse … Home Office Minister of State for Crime …	1/3
12 Oct 2015	Mrs Withers 2015-0371 · Hassan Shah Systemic policy deficiencies in emergency services included failing to obtain patient medical history during 999 calls, inadequate call-back procedures, poor data saving, …	East Midlands Northampton	East Midlands Ambulance Service Freeth Cartwright Solicitors Kettering General Hospital NHS Trust	0/3
9 Oct 2015	Patrick Carrick 2015-0374 · Karen Dilks There was an unexplained departure from the patient's management plan during rapid deterioration, crucial blood results were not actioned, and nursing/medical notes …	North East Newcastle Upon Tyne	North Tyneside General Hospital	1/1