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 269 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
23 Jul 2015	Lynn Poyser 2015-0295 · ARW Forrest Existing guidance for co-prescribing Lisinopril and Spironolactone may not sufficiently highlight the risks of renal deterioration and hyperkalaemia, indicating a need for …	East Midlands South Lincolnshire	Lincolnshire Community Health Services Medicines and Healthcare products Regulatory … National Institute for Health and …	0/3
23 Jul 2015	Ashley Matthews 2015-0297 · David Urpeth Insecure perimeter fencing allowed unauthorized access to the railway site, and there was a lack of warning signs for high voltage cabling …	West Midlands Black Country	British Transport Police	1/1
23 Jul 2015	Michael Hanlon 2015-0294 · Philip Sharp An inefficient boat entry system, potential crew tiredness from additional shifts, and inadequate monitoring of working hours raised safety concerns for crewmembers.	North West Cumbria	Plateus Ltd	1/1
23 Jul 2015	Doreen England 2015-0291 · Louise Hunt The patient at high risk of pressure sores lacked a care plan, staff lacked knowledge and training in prevention, and the ward …	West Midlands Birmingham and Solihull	Birmingham and Solihull Mental Health … Department of Health and Social … NHS England	1/3
22 Jul 2015	James McGeown 2015-0506 · Andrew Cox An undulation in the road surface caused a loss of vehicle control at higher speeds, posing a significant risk to unsuspecting drivers.	West Midlands Worcestershire	Worcestershire County Council	0/1
21 Jul 2015	Anne Wilson 2015-0293 · Sonia Hayes Changes in police welfare check policy were not communicated to ambulance services, and police staff lacked training on managing mental health requests, …	London London (South)	London Ambulance Service Metropolitan Police	1/2
21 Jul 2015	Rachel Hollister 2015-0288 · Wendy James The report identifies that medical staff and porters either did not follow or were unaware of the Health Board's Protocols.	Wales Gwent	Aneurin Bevan University Health Board	0/1
20 Jul 2015	Bradley Hooper 2015-0285 · Grahame Short An inexperienced marshall, distracted by a mobile phone and improperly positioned, failed to observe a fatal collision. Club rules for marshall allocation …	South East Hampshire (Central)	M C Federation Portsmouth Motocross Club	1/2
20 Jul 2015	Luke Myers 2015-0292 · Andre Rebello HMP Liverpool miscalculated the deceased's sentence, which was a likely factor in his death. Additionally, prison discipline staff lacked current first aid …	North West Liverpool	National Offenders Management Service	1/1
20 Jul 2015	Paul Coxon 2015-0286 · Karen Dilks Inadequate signage for safe pedestrian crossing, lack of illuminated signs, and an inappropriate 50 mph speed limit on a complex slip road …	North East Newcastle Upon Tyne	Gateshead Council	1/1
20 Jul 2015	Edward Maher, James Dunsby and Craig Roberts 2015-0228 · Louise Hunt A new tracker system failed to identify static soldiers, commanders lacked awareness and training on critical heat illness guidance, and risk assessment …	West Midlands Birmingham & Solihull	Special Forces Defence	1/2
17 Jul 2015	Adam Connelly 2015-0284 · Rachael Griffin The low height of walls accessing a railway footbridge allowed easy public access to tracks, creating a significant risk of future fatalities …	North West Manchester (West)	British Transport Police Network Rail	1/2
17 Jul 2015	Masoud Ghaderi 2015-0283 · Peter Harrowing Inconsistent record-keeping for service user engagement and the absence of a dedicated staff member for reviewing risk assessments prevented identification of changing …	South West Avon	Avon and Wiltshire Mental Health … Care Quality Commission	1/2
16 Jul 2015	Isabella Drew 2015-0289 · Nicola Mundy Inadequate national guidance and audit procedures prevent healthcare providers from consistently advising pregnant women about whooping cough vaccination. Poor communication links between …	Yorkshire and the Humber South Yorkshire (East)	Department of Health and Social … NHS England	2/2
16 Jul 2015	John Lloyd 2015-0282 · Christopher Woolley Frequent failures in the hospital's electronic system to notify GPs of patient admissions jeopardised continuity of care and could lead to inappropriate …	Wales Cardiff and the Vale of Glamorgan	University of Wales, Cardiff University Hospital of Wales	0/2
16 Jul 2015	Stanley Oliver 2015-0281 · Alan Walsh The hospital lacked an official on-call rota and actual provision for GI Radiologists to perform critical procedures out of hours, particularly on …	North West Manchester (West)	Department of Health and Social … Salford Royal NHS Foundation Trust	2/2
15 Jul 2015	Karen O’Brien Roy Palmer The mental health service (SEPT) made clinical determinations without adequate inquiry or face-to-face assessment, overriding a GP's referral. The coroner questioned the …	London London (City)	First Response Team, South Essex … NICE	0/2
15 Jul 2015	Joyce Hartford 2015-0279 · Lisa Hashmi Nursing records, assessments, and discharge summaries were consistently incomplete and inaccurate, demonstrating no material improvement despite ongoing audits and posing recurrent patient …	North West Manchester (North)	Pennine Acute Hospitals NHS Trust	1/1
15 Jul 2015	Paul Kalnins 2015-0278 · Nadia Persaud Communications officers lacked current training and struggled with a complex database where critical risk information was not easily accessible or prominently displayed, …	London London (East)	Metropolitan Police	1/1
14 Jul 2015	Thomas Farrell 2015-0273 · Stephanie Haskey The care home failed to obtain a full prescription history from the GP, resulting in critical medications not being administered and creating …	East Midlands Nottinghamshire	Springfield Care Home	0/1