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 268 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
11 Aug 2015	John Hills 2015-0317 · Christopher Wilkinson Paraffin-based emollient creams lacked fire hazard warnings on labels and prescriptions, and risks were not communicated to a known smoker, highlighting a …	South East West Sussex	National Patient Safety Agency Chief Fire Officers Association Staffordshire Fire and Rescue Service	0/3
10 Aug 2015	Lorraine Bird 2015-0315 · Thomas Osborne There was a lack of protocol for assessing patients at the Plaster Room, and a patient was sent home without a medical …	East of England Bedfordshire and Luton	Coreys Mill Lane East & North Hertfordshire NHS … Herts. SG1 4AB Mr N Carver	2/5
8 Sep 2015	Craig Chappell Rosemary Baxter Inadequate information sharing and a lack of formal mechanisms for communicating family concerns hindered support. Prison staff also lacked sufficient guidance on …	Yorkshire and the Humber East Riding and Kingston Upon-Hull	HMP HUMBER (EVERTHORPE SITE)	0/1
7 Aug 2015	James Adams 2015-0315-wp25966 · Emma Carlyon A severe shortage of acute psychiatric beds in Cornwall forces inappropriate detention in police cells or distant out-of-county transfers, causing patient deterioration …	South West Cornwall and the Isles of Scilly	Department of Health and Social …	2/1
7 Aug 2015	Amanda Ellams 2015-0312 · John Pollard Substandard medical record-keeping, inadequate oxygen saturation monitoring, unsafe patient discharge, and a "flawed" unanswered out-of-hours district nursing telephone system collectively contributed to …	North West Manchester (South)	BMI Healthcare GTD Healthcare	1/2
7 Aug 2015	Gordon Atkinson 2015-0311 · Ian Arrow The report identifies that the deceased appeared to be living in unsuitable accommodation, neglecting himself, and had an inappropriate care package.	South West Plymouth, Torbay and South Devon	Plymouth City Council	0/1
7 Aug 2015	Kathleen Neville 2015-0310 · Christopher Woolley The absence of a Medication Reconciliation policy allowed medication errors to go undetected for too long, posing a significant risk of future …	Wales Cardiff and the Vale of Glamorgan	Aneurin Bevan University Health Board Betsi Cadwaladr University Health Board Cardiff and Vale University Health … Cwm Taf Morgannwg University Health …	0/9
6 Aug 2015	Robert Hogg 2015-0313 · Crispin Butler NHS Pathways' toddler/child assessment tools are failing to identify very sick children, a persistent and unaddressed risk despite prior investigations.	South East Buckinghamshire	Department of Health and Social …	2/1
6 Aug 2015	Thomas Thurling 2015-0309 · Jacqueline Lake Inadequate monitoring of medication changes, including lack of awareness and delayed reviews, coupled with the absence of a Care Co-ordinator during a …	East of England Norfolk	Norfolk and Suffolk NHS Foundation …	1/1
5 Aug 2015	Rubel Ahmed 2015-0308 · Stuart Fisher Detainees were locked in rooms overnight against recommendations, staff lacked robust detention awareness and refresher training, and crucial information like removal directions …	East Midlands Lincolnshire (Central)	Home Office Ministry of Justice	1/2
4 Sep 2015	Mary James Sarah-Jane Richards Inadequate INR monitoring, uncertainty regarding Warfarin intake, and poor communication between healthcare providers led to unadjusted anticoagulation therapy for a dementia patient, …	Wales Powys	Bryntirion Surgery Care & Social Services Inspectorate, … Aneurin Bevin University Health Board Cwm Taf Morgannwg University Health …	0/8
4 Aug 2015	Jeffrey Warren 2015-0307 · Bridget Dolan Neither council formally reviewed the case, delaying lessons. A hazardous electric fire was left unaddressed, and social work staff inappropriately requested police …	South East West Sussex	Crawley Borough Council West Sussex County Social Services	1/2
3 Aug 2015	Michael Quinn 2015-0304 · Peter Bedford Hospital guidance for pre-operative blood glucose levels was inconsistent with national guidelines and research, highlighting confusion about optimal levels for surgical patients …	South East Berkshire	other private hospitals that utilise … Royal Berkshire Hospital Trust	0/2
30 Jul 2015	Anthony Dwyer 2015-0249 · Andrew Walker The guidance provided to the Trust for the general management of long-term tracheostomy patients with complex medical needs was inadequate.	London London (North)	Department of Health and Social …	1/1
30 Jul 2015	Casey Garrett 2015-0305 · Thomas Osborne Inappropriate midwifery care by a student and midwife, including insufficient fetal monitoring, misinterpretation of CTG, and failure to escalate, led to an …	East of England Bedfordshire and Luton	Health Education East of England LET Board	1/2
30 Jul 2015	Giuseppina Incisivo 2015-0303 · Joseph Turner Blind spot mirrors on high-fronted vehicles offer insufficient visibility for pedestrians, especially the elderly. A lack of secondary warning systems leads to …	South East West Sussex	Department for Transport	1/1
28 Jul 2015	William Bows 2015-0301 · 2015-0301 The report identifies a lack of protocols for advising primary care providers on monitoring patients prescribed Amiodarone, specifically concerning liver function, thyroid …	Yorkshire and the Humber South Yorkshire (East)	Northern General Hospital	1/1
27 Jul 2015	Arthur Cook 2015-0300 · Sarah-Jane Richards Low staffing of Tissue Viability Nurses, inadequate pressure ulcer documentation, and a lack of integrated skin care across services contributed to progression …	Wales Powys, Bridgend and Glamorgan	Aneurin Bevan University Health Board Bryntirion Surgery Cwm Taf Morgannwg University Health … Four Season’s Healthcare Home	0/5
24 Jul 2015	Simon Reynolds 2015-0296 · Maria Voisin Lack of documented risk assessments on admission, inadequate record-keeping, and insufficient staff training on setting observation levels, assessing suicide/self-harm risk, and communicating …	South West Avon	Avon and Wiltshire Mental Health …	0/1
24 Jul 2015	Carl Smith 2015-0298 · Elizabeth Earland Custodial and welfare checks for a prisoner on an ACCT and Methadone Stabilisation Programme were insufficient, and information sharing related to these …	South West Exeter and Greater Devon	Dorset Healthcare University NHS Foundation … HMP Exeter	1/2