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 270 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
14 Jul 2015	Emma Carpenter 2015-0276 · Stephanie Haskey Critical specialist eating disorder services for children lacked long-term funding and inpatient bed provision. Insufficient funding for school nurses caused poor communication …	East Midlands Nottinghamshire	Department for Education Department of Health and Social … NHS England	3/3
14 Jul 2015	Kenneth Bailey 2015-0275 · John Pollard Limited manning hours at a local fire station caused delayed emergency response times, which encouraged untrained neighbours to undertake dangerous rescues, increasing …	North West Manchester (South)	Greater Manchester Fire and Rescue …	1/1
14 Jul 2015	Janine Kaiser 2015-0272 · Margaret Jones A pressure sore management plan was poorly followed, with falsified records, missed turns, and inadequately trained staff in record-keeping and mattress management. …	West Midlands Stoke on Trent and North Staffordshire	New Park Residential Home Stoke-on-Trent City Council	1/2
13 Jul 2015	Barbara Harrison 2015-0277 · John Pollard Inappropriate physiotherapy contributed to surgical complications, and critical equipment failed during emergency surgery due to flat batteries, leading to a 'panic situation'. …	North West Manchester (South)	BMI Healthcare Limited	0/1
13 Jul 2015	Douglas Birch 2015-0274 · Patricia Harding Prison officers were either unaware of or failed to follow instructions requiring them to elicit a response from prisoners upon cell unlocking. …	South East Mid Kent and Medway	HMP Swaleside	1/1
13 Jul 2015	Wiktoria Was 2015-0271 · Tony Badenoch Police pursuits showed insufficient regard for injured third parties, and lessons from previous pursuit-related deaths were not adequately learned or disseminated. Officers …	London London (Inner South)	Metropolitan Police	1/1
10 Jul 2015	Dorothy McDermott 2015-0266 · Simon Nelson A vulnerable patient was inappropriately placed in a residential care home without nursing care or staff trained for her needs. A lack …	North West Manchester (North)	Department of Health and Social … Littleborough Care Home Pennine Care Trust Rochdale Metropolitan Borough Council	0/4
10 Jul 2015	Cameron Laing 2015-0268 · Elizabeth Earland Soldiers lacked critical understanding of trailer braking systems and safe extraction methods, leading to a fatal accident. The Ministry of Defence irrationally …	Exeter and Greater Devon	Ministry of Defence	1/1
10 Jul 2015	Colin Moulton 2015-0267 · Simon Nelson Critical patient information was lost during verbal paramedic-to-triage nurse handovers. Additionally, the ambulance service failed to notify the hospital of their presence …	North West Manchester (North)	Department of Health and Social … Messrs. Weightmans North West Ambulance Service	1/3
9 Jul 2015	Michael George 2015-0264 · Andrew Harris Senior management may have attached insufficient importance to previous PFD reports regarding the physical healthcare of mentally ill patients, and there was …	London London (Inner South)	South London and Maudsley Trust	1/1
9 Jul 2015	Toni Piel 2015-0263 · Matthew Cox A patient was discharged home after a head injury without assessing their home circumstances or documenting discharge risk factors, violating NICE guidelines …	North West Manchester (North)	Department of Health and Social … Pennine Acute Hospitals NHS Trust	1/2
9 Jul 2015	Alun Walters 2015-0262 · Sarah Jane-Richards The medical practice failed to use computer software for prescription decisions, breached its anti-coagulation register contract, and lacked systems for notifying GPs …	Wales Powys, Bridgend and Glamorgan Valleys	Aneurin Bevan University Health Board Cwm Taf University Health Board National Assembly for Wales North Community Mental Health Team	0/5
8 Jul 2015	Ronald Laidiar 2015-0270 · John Pollard The police investigation was severely inadequate, failing to secure the scene, account for missing items, properly investigate the source of blood, or …	North West Manchester (South)	Greater Manchester Police	0/1
8 Jul 2015	Meryl Parry 2015-0259 · Robert Chapman A lack of mandatory system for residential homes to seek Social Services advice before discharging residents creates a serious risk that discharged …	North West Cumbria	Cumbria County Council Green Lane Care Homes Limited	1/2
7 Jul 2015	Yvonne Davies and Andrew Davies 2015-0261 · John Pollard An off-duty police officer, personally involved with the deceased, compromised the crime scene by breaking in and contaminating evidence before and after …	North West Manchester (South)	Greater Manchester Police	0/1
7 Jul 2015	Michael Thorley 2015-0260 · John Pollard There was an inexcusable delay in emergency entry and a lack of clear policy for forced entry. Police failed to thoroughly investigate …	North West Manchester (South)	Greater Manchester Police	1/1
7 Jul 2015	Arthur Fry 2015-0258 · Ian Smith A communication breakdown between the MRI department and the consultant's team led to a critical MRI scan being cancelled due to unknown …	West Midlands Stoke on Trent and North Staffordshire	University Hospital of North Staffordshire	1/1
6 Jul 2015	Tommy Faisali Fiona Wilcox Psychiatric GP referrals are handled by unqualified staff, and risk assessments are not consistently completed or documented, leading to uncommunicated patient risks …	London London Inner (West)	Central and North West London …	0/1
6 Jul 2015	John Clarke 2015-0256 · Kevin McLoughlin The City Council's highway inspection system and asset database were ineffective, failing to identify a missing road sign and defective lighting for …	London London Inner (West)	City Of Westminster	1/1
6 Jul 2015	George Boulton 2015-0255 · Lydia Brown Delays in emergency stroke care arose from the GP failing to escalate, a bed bureau lacking emergency re-routing, and ambulance services not …	East Midlands Leicester City and Leicestershire South	East Midlands Ambulance Service NHS England University Hospital Leicester	1/3