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 265 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
9 Oct 2015	Suzanne Greenwood 2015-0370 · Alan Walsh Lack of systems and protocols for contacting patients who miss appointments, informing GPs of non-attendance or discharge, and ensuring continuity of care …	North West Manchester (West)	Priory Hospital	1/1
8 Oct 2015	Rebecca Jones 2015-0504 · Edward Thomas Concerns involved the failure to conduct a Section 136 mental health assessment within the expected three-hour timeframe, and the need for facilities …	East of England Hertfordshire	Department of Health and Social …	1/1
8 Oct 2015	Maureen Chatterley 2015-0404 · Alan Walsh Lack of investigation into alleged medication overdose and inadequate stock control for non-controlled drugs on wards, preventing verification of medication quantities and …	North West Manchester (West)	Royal Bolton Hospital	1/1
8 Oct 2015	Solomon Bealey 2015-0403 · Jacqueline Lake Despite initial concerns about a patient's suicidal ideation and a history of self-harm, no effective follow-up action was taken after failed contact …	East of England Norfolk	Norwich Practices Health Centre	1/1
7 Oct 2015	Edward Gascoigne 2015-0401 · R Brittain The report identifies that relevant information about the deceased's illness was in disparate records, making it difficult for clinicians, especially the psychiatric …	London London Inner (North)	Department of Health and Social …	1/1
7 Oct 2015	Geoffrey Parry 2015-0400 · Andrew Barkley Critical ECG test results were unavailable pre-surgery due to systemic record management issues. An unlabelled intravenous line was accidentally disconnected, highlighting a …	Wales Cardiff and the Vale of Glamorgan	Cardiff and Vale University Health …	1/1
7 Oct 2015	Dilys Jenkins 2015-0399 · Christopher Woolley Tracheostomy tube manufacturers may not be keeping pace with population changes, leading to tubes of potentially inappropriate length which could increase dislodgement …	Wales Cardiff and the Vale of Glamorgan	Intensive Care Society of England …	0/1
5 Oct 2015	Peter Furness 2015-0398 · John Gittins The care home lacked a documented process for escalating incidents and concerns to trigger multi-disciplinary team meetings for reviewing vulnerable residents' risk …	Wales North Wales (East and Central)	Nant y Gaer Hall Nursing …	1/1
2 Oct 2015	Rosina Drury 2015-0397 · Andrew Harris The absence of a pre-operative orthogeriatric review for patients with femoral neck fractures risks inappropriate cemented hemiarthroplasty, potentially leading to fatal bone …	London London Inner (South)	Kings College Hospital	0/1
1 Oct 2015	John Lomas 2015-0396 · Margaret Jones Inadequate risk assessment of river conditions, lack of essential safety protocols for white water rafting (e.g., training, safety kayak, appropriate raft capacity), …	West Midlands Stoke-on-Trent and North Staffordshire	Sports Camp Tirol	1/1
1 Oct 2015	Charles Rayner 2015-0367 · Crispin Oliver The report identifies that the crossover point lacks a deceleration lane and there is no prohibition on right turns with appropriate signage.	North East County Durham and Darlington	Highways England	0/1
1 Oct 2015	Kenneth McCurdy and Mary McCurdy 2015-0369 · Crispin Oliver The absence of clear signage at a central reservation gap fails to indicate prohibited right turns or U-turns for east-bound vehicles, creating …	North East County Durham and Darlington	Highways England	1/1
30 Sep 2015	Jean Hannon 2015-0458 · Michael Singleton A critical diagnosis (autonomic dysreflexia) was not sufficiently highlighted in medical records, leading to a consultant's unawareness during a later admission and …	North West Blackburn, Hyndburn and Ribble Valley	East Lancashire Healthcare NHS Trust	1/1
29 Sep 2015	Parv Patel 2015-0457 · Andrew Walker The report identifies that PEWS scores may not reflect current research into child illness, particularly in cases of sepsis, and may distract …	London London (North)	Department of Health and Social …	1/1
29 Sep 2015	Lee Boden 2015-0394 · Thomas Osborne Lack of pre-release planning, delayed discovery, and the absence of a protocol for continuous monitoring of vulnerable new residents contributed to the …	South East Milton Keynes	National Probation Service	1/1
29 Sep 2015	Ethan Johnson 2015-0393 · Thomas Osborne There was a critical lack of leadership and support for junior staff managing an abnormal CTG trace, compounded by a hierarchical system …	South East Milton Keynes	Milton Keynes Hospital	1/1
28 Sep 2015	John Roberts 2015-0389-wp25035 · Caroline Beasley-Murray The current junction design encourages dangerous pedestrian crossings over the central reservation due to an unclear, distant designated crossing, posing significant risk.	East of England Essex	Highways Agency	0/1
28 Sep 2015	Tania Hristova 2015-0392 · Claire Balysz The patient received antidepressant medication for over five years without adequate review and was not offered additional psychological therapies such as counselling …	South West Wiltshire and Swindon	New Court Surgery	1/1
28 Sep 2015	Harry Pryal 2015-0391 · Alan Walsh A significant lack of recorded medical advice between trusts, conflicting interpretations of service agreements, and failure to hold mandated liaison meetings resulted …	North West Manchester (West)	5 Boroughs Partnership NHS Trust Wrightington Wigan & Leigh, Royal … Department of Health and Social … Wigan Borough Clinical Commissioning Group	4/4
25 Sep 2015	Violet Cloudsdale 2015-0387 · Paul O’Donnell The care home lacked risk assessments and consent for wheelchair lap-belt use, and unclear guidance on their application raised concerns about unlawful …	North West Cumbria	Care Quality Commission Risedale Estates Limited	0/2