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 267 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
3 Sep 2015	Kala Skinner Peter Harrowing Clinical advisors missed critical 'red flags' and gave inappropriate advice due to inadequate training, mentoring, and auditing, leading to failures in recognising …	South West Avon	Care Quality Commission South Western Ambulance Service NHS …	0/2
2 Sep 2015	Rosalind Baird David Horsley There is no formal national monitoring scheme for inexperienced surgeons, despite the existence of effective local models, risking patient safety during surgical …	South East Portsmouth and South East Hampshire	Dept. of Health	0/1
1 Sep 2015	John Robinson David Urpeth The unavailability of a psychiatric bed for Mr Robinson led to his deteriorating condition and death, raising concerns about insufficient mental health …	Yorkshire and the Humber South Yorkshire (West)	Clinical Commissioning Group	0/1
1 Sep 2015	Darren Browne Andrew Harris A vulnerable adult with high suicide risk was prevented from contacting family, a decision that failed to properly balance his acute needs …	London London Inner (South)	Police of the Metropolis	0/1
28 Aug 2015	Isabel Richardson Jacqueline Lake The school's Pastoral Team lacked clear purpose, operational structure, and adequate staff training, rendering it an insufficiently robust system to address student …	East of England Norfolk	Hewett School	0/1
27 Aug 2015	Frederick Sutton John Pollard Suboptimal staffing, poor staff training in drug administration and cardiac arrest response, unread nursing notes, incompatible computer systems, and inaccurate patient information …	North West Manchester (South)	Stockport NHS Foundation Trust	0/1
27 Aug 2015	Eliza Simpson Emma Brown The care home lacked a system for renewing deprivation of liberty orders, risking unauthorized detention. The absence of CCTV also hindered investigation …	West Midlands Birmingham and Solihull	Birmingham City Council Care Quality Commission	0/2
20 Aug 2015	Andrew Roberts John Gittins Inaccurate and delayed completion of the Transfer of Care Form by a doctor prevented critical patient information from being immediately available to …	Wales North Wales (East and Central)	North Wales Police BCUHB, Ysbyty Gwynedd	0/2
20 Aug 2015	Joyce Plested John Pollard The unsafe positioning of a zebra crossing too close to a mini-roundabout creates a high-risk junction for pedestrians and drivers, and a …	North West Manchester (South)	J. Sainsbury PLC Trafford Metropolitan Borough Council	0/2
20 Aug 2015	Elsie Clarke John Pollard The report identifies a lack of staff training in calling emergency services or arranging GP visits, poor observation of residents, failure to …	North West Manchester (South)	GTD Healthcare Hurst Hall Care Centre	0/2
20 Aug 2015	Sharon Henshall Claire Hammond The absence of a VTE risk assessment tool in the Emergency Department for patients discharged with lower limb immobilisation, coupled with varied …	North West Preston and West Lancashire	LTHTR LTHTR	0/2
19 Aug 2018	David Sweeney ME Hassell A call to the London Ambulance Service regarding an unconscious man did not prompt a red prioritisation, raising concerns about the handling …	London London Inner (North)	London Ambulance Service NHS Trust	0/1
19 Aug 2015	Barry Pike Andrew Cox The specific matters of concern are detailed in an external report by Dr Stephen Hoole, which was not provided here.	South West Plymouth Torbay and South Devon	Plymouth Hospitals NHS Trust	0/1
18 Aug 2015	Stephen Richardson 2015-0507 · Ian Smith Nursing staff consistently failed to adhere to critical dietary and drink restrictions for a patient with Down's Syndrome, despite explicit instructions, raising …	West Midlands Stoke-on-Trent & North Staffordshire	University Hospital of North Staffordshire	1/1
17 Aug 2015	Ian Morley 2015-0320 · Chinyere Inyama A patient's deteriorating condition failed to trigger a necessary fresh risk assessment, compounded by inadequate fire risk management at the care facility.	London London (West)	Adult Social Services Greenrod Place	0/2
12 Aug 2015	Ben Hiscox T Moore The distance between the football touchline and clubhouse fell below FA safety recommendations, placing players at risk of injury or death, with …	South West Avon	The FA Group	0/1
12 Aug 2015	Eileen Smith 2015-0500 · Edward Thomas The report detailed gross failings of nursing care for a patient with a learning disability and highlighted the risk of making assumptions …	East of England Hertfordshire	Department of Health and Social …	1/1
12 Aug 2015	Thelma Jones 2015-0318 · Veronica Hamilton-Deeley The provided text only states the report concerns the Acute Medical Unit (AMU) where the deceased was admitted, without specifying the issues …	South East Brighton and Hove	Brighton and Sussex University Hospitals …	1/1
12 Aug 2015	Dean Joseph 2015-0319 · ME Hassell Inconsistent understanding of armed containment, lack of trained negotiator guidance for first responders, and sub-optimal post-incident procedures undermined the investigation and public …	London London Inner (North)	Metropolitan Police Service	1/1
11 Aug 2015	Julia Hayward 2015-0321 · Simon Wickens Discharged mental health patients' care plans, especially those involving family obligations, were only verbally agreed and not documented or provided, leading to …	South East Surrey	Department of Health and Social …	1/1