Vera Williams
AI-generated concerns summaryThe report identifies a lack of a digital system for doctors and staff in the Emergency Department.
Addressed to: Betsi Cadwaladr University NHS Trust
Source · Prevention of Future Deaths
Prevention of Future Deaths Reports
Browse 6,493 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.
Reports
Brian Shillinglaw
AI-generated concerns summaryThe provided text is incomplete and does not contain specific concerns.
Addressed to: Brighton and Sussex University Hospitals NHS Trust; Care Quality Commission; NHS England; Clinical Commissioning Group; Goodlaw Solicitors; National Patient Safety Agency; Department of Health; Sussex Partnership Trust
Carl Hughes
AI-generated concerns summaryThe coroner raised concerns that body protection is not mandatory for motor cross competitors, believing it would have likely prevented the fatal injuries sustained in this case.
Addressed to: Motor Cross Federation
Michael Logue
AI-generated concerns summaryThe coroner noted that the GP did not conduct a physical examination of the patient during a home visit, despite the patient complaining of pain following biliary reconstruction surgery.
Addressed to: Central Surgery
David Pooley
AI-generated concerns summaryThe coroner noted that a named nurse was not allocated until the day before the patient's death, contrary to trust policy. This resulted in essential duties like risk assessments, care plans, and family contact not being carried out.
Addressed to: South Essex Mental Health Partnership Trust; Lancashire Care NHS Trust
Peter Buckle
AI-generated concerns summaryThe coroner identified that a risk assessment was not updated for a new, unsafe work method, and observed a lack of health and safety culture among ground-level employees despite prior training.
Addressed to: Wayland Farms Limited
Richard Green
AI-generated concerns summaryConcerns were raised that previous self-harm incidents recorded on SystmOne were not identified by prison medical staff due to insufficient review of records and usability issues with the system, leading to a lack of awareness of the prisoner's risk.
Addressed to: Ministry of Justice; National Offender Management Service
Marie Quinn
AI-generated concerns summaryThe coroner identified concerns regarding medication management at Richmond House Nursing Home, where excess medication was not queried. Inaccurate hospital discharge notes led to the premature cessation of prophylaxis treatment for a patient.
Addressed to: HC-One Limited; Richmond House Nursing Home
Steven Jackson
AI-generated concerns summaryThe report highlights a paramedic's ineffective use of the sepsis screening tool and identifies a need for effective training for ambulance staff on the tool's application and appropriate patient conveyance to hospital.
Addressed to: Bevan Brittan Law Firm; East of England Ambulance Service NHS Trust; General Medical Council; Irwin Mitchell Solicitors; Southend Hospital Legal Services; Weightmans Solicitors
Jacqueline Williams
AI-generated concerns summaryThe coroner noted insufficient systems for mental health referrals, allowing human error to go undetected. Emergency department staff could not confirm referral acceptance, nor could the Mental Health Liaison Team identify patients awaiting assessment.
Addressed to: East Lancashire NHS Trust
Jean Gillespie
AI-generated concerns summaryThe coroner identified that a senior care staff member administering medication was unaware of a resident's life-threatening condition and its urgency. Care home records lacked information on the condition, its symptoms, and the purpose of prescribed medication, presenting a risk if replicated.
Addressed to: Alexandra Court Care Home
Connor Sparrowhawk
AI-generated concerns summaryThe coroner noted concerns about the effectiveness and practicality of bath time observations for patients with epilepsy, as sound-only monitoring may not prevent drowning. The patient record system (RIO) also lacks a dedicated field for epilepsy history, limiting staff access to vital information.
Addressed to: CQC; Southern Health NHS Foundation Trust
Dennis Stark
AI-generated concerns summaryThe coroner noted that the absence of a lift at Newton House significantly delayed the emergency medical evacuation of an unresponsive resident from the second floor. This raises concerns about the safe removal of future residents requiring urgent medical attention, especially those with physical limitations.
Addressed to: Newton House (formerly Regency Hospital)
Mary Bloom
AI-generated concerns summaryThe coroner identified non-compliance with Trust policy for heparin administration, specifically regarding weighing the patient, consulting haematology for low weight, and re-attempting baseline bloods. Critical information for underweight patients on the heparin poster was also not sufficiently visible.
Addressed to: Barking, Havering and Redbridge University Hospitals NHS Trust
Hilda Haughton
AI-generated concerns summaryUnraised cot sides led to a patient falling from bed, and hospital staff showed a lack of candour about the incident. Concerns were also raised about the increased time taken for fire doors to close at the hospital.
Addressed to: Secretary of State for Health; Tameside Hospital NHS Foundation Trust
Tamara Mills
AI-generated concerns summaryThe coroner noted a lack of coordinated, long-term management for the child's chronic asthma, with care focused solely on acute events and no single individual taking overall responsibility. This was compounded by poor communication between services and issues with specialist paediatric referrals.
Addressed to: Farnham Medical Centre; Health Education England; National Institute for Health and Care Excellence; Newcastle & Gateshead Clinical Commissioning Group; Newcastle NHS Trust; NHS England; South Tyneside Clinical Commissioning Group; South Tyneside NHS Trust; Sunderland NHS Trust
Florence Lowe
AI-generated concerns summaryThe coroner identified concerns regarding a 60mph speed limit on a road with residential properties, a busy petrol station, and a hotel, noting it was higher than other local roads. There was also no pedestrian crossing on the south side of a nearby roundabout despite large residential areas accessing it.
Addressed to: Staffordshire County Council
Kevin Forster
AI-generated concerns summaryThe coroner identified a serious drug problem at HMP Durham and a lack of staff awareness and training regarding drug and overdose policies. There was insufficient guidance on managing overdoses, leading to delays in emergency response and a degree of complacency among staff.
Addressed to: G4S; National Offender Management Service
Christopher Smith
AI-generated concerns summaryA 12-minute delay occurred in police contacting the ambulance service due to a communication breakdown between Greater Manchester Police and Motorway Control. The coroner identified a need for a clear procedure to immediately establish who is responsible for calling an ambulance.
Addressed to: Greater Manchester Police
Bartosz Bortniczak
AI-generated concerns summaryThe coroner noted that the 40mph speed restriction is currently applied after a bend on the road, despite a history of incidents. It was recommended that the 40mph restriction be moved to apply prior to the bend.
Addressed to: Doncaster Highways Services