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 266 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
23 Sep 2015	Dorothy Delaney 2015-0402 · Rachael Griffin The concurrent prescription of antiplatelet and anticoagulant medications without specialist advice contradicted national guidelines, significantly increasing haemorrhage risk, especially given the patient's …	North West Manchester (West)	Alexander House Health Centre Platt Bridge Health Centre	0/2
22 Sep 2015	Stuart Knight 2015-0385 · Stuart Fisher Significant and unacceptable delays in ambulance dispatch occurred for an unconscious patient with a serious head injury, potentially prejudicing the outcome.	East Midlands Central Lincolnshire	East Midlands Ambulance Services	1/1
22 Sep 2015	William Harnell 2015-0384 · Andrew Cox Significant national delays in X-ray reporting due to a shortage of qualified radiologists pose a risk to patient care across the UK.	South West Plymouth, Torbay and South Devon	Department of Health and Social … Plymouth Hospitals NHS Trust Social Services Truro Cornwall	3/3
22 Sep 2015	Emma Waring 2015-0383 · Simon Nelson The absence of compulsory automatic water suppression systems in residential properties, especially for vulnerable individuals, represents a significant fire safety risk.	North West Manchester (North)	Department for Communities and Local …	1/1
18 Sep 2015	Liam Smith 2015-0382 · Geraint Williams Mandatory ACCT procedures for self-harm risk were not followed, critical medical information was poorly disseminated within the prison, and limited healthcare interaction …	West Midlands Worcestershire	Governor HMP Hewell Worcestershire Health and Care Trust	1/2
18 Sep 2015	Christianne Shepherd 2015-0338 · David Hinchliff The report calls for a publicly accessible central register for tour operators to record hotel safety information, improved collaboration between tour operators …	Yorkshire and the Humber West Yorkshire (East)	ABTA – The Travel Association Louis Group including the Louis … The Federation of Tour Operators Department for Culture, Media and …	0/7
17 Sep 2015	Fiona Lewis 2015-0441 · Dr Peter dean There's a concern about ensuring healthcare professionals are adequately trained in resuscitation and can respond appropriately to patient collapse.	East of England Suffolk	Ipswich Hospital	0/1
17 Sep 2015	Lee Bates 2015-0381 · Andrew Harris A critical lack of communication between psychiatry and sleep apnoea specialists, along with inadequate guidance and monitoring protocols for OSA patients receiving …	London London Inner (South)	Guys and St Thomas NHS … Cambian Group	1/2
16 Sep 2015	David Charles 2015-0366 · Caroline Beasley-Murray Street lighting was switched off on a dark night, significantly reducing pedestrian visibility and contributing to a fatal collision, despite drivers being …	East of England Essex	Essex County Council Essex Highways Agency	0/2
16 Sep 2015	Adil Habib 2015-0380 · ME Hassell Lack of specific gate location information for prisons during 999 calls, compounded by London Ambulance Service's system not uniformly supporting alternative gate …	London London Inner (North)	HMP Pentonville London Ambulance Service NHS Trust National Offender Management Service	2/3
15 Sep 2015	Karen Clayton 2015-0388 · John Pollard The road layout has insufficient segregation for mixed traffic, with a confusing contra-flow cycle lane and unclear signage, creating a dangerous environment …	North West Manchester (South)	Secretary of State for Transport Trafford Metropolitan Borough Council	1/2
14 Sep 2015	Anthony Cleveland 2015-0442 · Dr Peter Dean A gym lacked immediate problem recognition, adequate resuscitation, risk assessments for users, qualified first aiders, and formal national guidance on fitness centre …	East of England Suffolk	Health and Safety Executive	0/1
14 Sep 2015	Stephen O’Malley 2015-0363 · Andre Rebello Rescue was delayed due to the standby diver being unable to locate a critical harness c-clip, as pre-dive protocol checks do not …	North West Liverpool & Wirral	SubCPartner	2/1
11 Sep 2015	George Ainsworth Alan Walsh A dangerous road junction has blind spots and limited driver visibility, creating a "pinch point" for large vehicles and putting pedestrians at …	North West Manchester (West)	Bolton Council	1/1
11 Sep 2015	Ronald Bonfield Graeme Hughes Inconsistent practices for monitoring district nurse compliance with delegated INR testing across GP surgeries create a risk of unmonitored over-anticoagulation.	Wales Powys	England and Wales Cwm Taf Morgannwg University Health … National Assembly for Wales Practice 1, Keir Hardie Health …	0/4
11 Sep 2015	Thomas Nicholls Alan Walsh The report identifies care staff lacking training in PEG feeding, specifically regarding mobility and handling, and the failure to report a related …	North West Manchester (West)	Orchard Care Homes The Hamlet	0/1
8 Sep 2015	David Efemena Nadia Persaud A cadet training site lacked defibrillators and AED-trained first aiders, with challenging emergency access. There were also ineffective communication checks between staff …	London London (East)	Ministry of Defence	0/1
8 Sep 2015	Ian Emsley Elizabeth Earland Inadequate formal guidance for healthcare staff on assessing re-offending and escape risk contributed to delays in compassionate release or transfer decisions for …	South West Exeter and Great Devon	HMP Exeter HMP Portland	0/2
8 Sep 2015	Andrew Frere Neil Cameron A national prison instruction for 24-hour doctor review is impracticable and ignored. Case managers also fail to read ongoing observations during ACCT …	Yorkshire and the Humber South Yorkshire (East)	Equalities, Rights and Decency Group, …	0/1
3 Sep 2015	May Hall John Pollard Care home staff lacked awareness and clear training on fall reporting policies and how to contact emergency services, indicating a need for …	North West Manchester (South)	Bourne House	0/1