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 271 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
6 Jul 2015	Phyllis Broomhead 2015-0290 · Nicola Mundy Care home staff lacked training in head injury protocols and record-keeping, while safeguarding screening was insufficient. There's a systemic gap in monitoring …	Yorkshire and the Humber South Yorkshire (East)	Rotherham Metropolitan Borough Council	1/1
3 Jul 2015	Davina Tavener 2015-0252 · Alan Walsh Current aviation regulations fail to mandate critical medical equipment like defibrillators and airway adjuncts on aircraft, significantly reducing a passenger's chance of …	North West Manchester (West)	Civil Aviation Authority European Aviation Authority Irish Aviation Authority	3/3
2 Jul 2015	Patricia Holmes 2015-0254 · Rachel Redman The A&E doctor failed to recognize the serious risk of internal bleeding in a patient with multiple fractured ribs and on anticoagulation …	South East Kent Central and South East	East Kent Hospitals University NHS …	1/1
2 Jul 2015	Gail Prentice 2015-0253 · Sarah-Jane Richards There is no mandatory requirement for surgeons to acknowledge reading relevant Health Board and national clinical guidelines, potentially leading to inconsistencies in …	Wales Powys, Bridgend and Glamorgan Valleys	Cwm Taf University Health Board National Assembly for Wales	0/2
2 Jul 2015	David Hallett 2015-0250 · Andrew Barkley HMP Rye Hill's healthcare was inadequately resourced and unprepared for its re-roll to house sex offenders, resulting in substandard patient care. This …	Wales Powys, Bridgend and Glamorgan Valleys	HMP Parc HMP Rye Hill National Offender Management Service The Chief Coroner	0/4
1 Jul 2015	Mary Hyden 2015-0251 · Andrew Haigh A consultant neurologist is working excessive hours, including 7-day weeks and 14-hour shifts, which significantly increases the potential for medical errors and …	West Midlands Staffordshire (South)	University Hospital North Midlands	1/1
30 Jun 2015	Colette Hughes 2015-0246 · Selena Lynch An easily accessible wall, despite meeting regulations, has been the site of multiple deaths and poses a danger, particularly to impaired individuals. …	London London (South)	Hammerson Plc	1/1
30 Jun 2015	Blaise Farry 2015-0269 · Sean Cummings Insufficient staffing levels at HMP Wormwood Scrubs prevent the implementation of a nominated Officer scheme, despite prior recommendations, impacting prisoner welfare and …	London London (West)	HMP WORMWOOD SCRUBS	0/1
29 Jun 2015	Michael Bovell 2015-0248 · Andrew Walker The RSSB Rule Book's provisions for stopping trains are insufficient, prioritizing potential train damage over human life. Even cautioned trains can strike …	London London (North)	Rail Safety and Standards Board	0/1
29 Jun 2015	Davin Short 2015-0245 · David Osborne The prison's lack of an electronic cell bell recording system and unclear guidance on radio use for healthcare staff create risks of …	East of England Norfolk	HMP Wayland	2/1
26 Jun 2015	Alec Mathias 2015-0247 · Elizabeth Earland Critical drug sensitivity information was not included in discharge letters sent to the patient's GP, nor was it highlighted in hospital records, …	South West Exeter and Greater Devon	Royal Devon and Exeter Hospital	0/1
26 Jun 2015	Brian Gillard 2015-0244 · Alan Walsh A critical breakdown in patient handover between hospital departments led to ward staff being unaware of a patient's need for ambulatory oxygen, …	North West Manchester (West)	Royal Bolton Hospital	0/1
26 Jun 2015	Summer Robertson and Alice Barnett 2015-0243 · John Ellery There was a critical lack of awareness and specific risk assessment for rip currents, inadequate warnings for those entering the water, and …	West Midlands Shropshire, Telford and Wrekin	Lattitude Global Volunteering	0/1
26 Jun 2015	Richard Turner 2015-0242 · James Newman Light goods vehicles with significant rear blind spots are widely used without mandatory reversing aids like cameras or audible warnings, increasing the …	East Midlands Derby and Derbyshire	Department for Transport	0/1
25 Jun 2015	Lottie Reid 2015-0241 · Margaret Jones There were critical medication discrepancies between the discharge letter and the administration chart, with no clear protocol for checking these errors, especially …	West Midlands Birmingham and Solihull	Good Hope Hospital	1/1
24 Jun 2015	Anthony Geerts 2015-0240 · Veronica Hamilton-Deeley The provided text is incomplete and does not contain any discernible coroner's concerns.	South East Brighton and Hove	Brighton and Sussex University Hospital … Princess Royal Hospital	1/2
24 Jun 2015	Alice Mead 2015-0239 · Veronica Hamilton-Deeley Significant failings in mental health care involved the absence of a care coordinator, ignored patient requests for medication review, and an unacceptably …	South East Brighton and Hove	Sussex Partnership NHS Foundation Trust	1/1
23 Jun 2015	Steven Curtis Darren Salter There are safety concerns regarding Maplin N19KJ telescopic ladders, with 43,000 sold, warranting investigation into a potential catastrophic failure and the origin …	South East Oxfordshire	Derbyshire Trading Standards Division	0/1
22 Jun 2015	Jan McLean 2015-0237 · Richard Travers Police officers require full and adequate training to thoroughly interrogate all details relating to warning markers held on the PNC to prevent …	South East Surrey	Surrey Police	0/1
22 Jun 2015	Kathleen Eaton 2015-0236 · John Pollard An emergency trust link officer lacked formal medical assessment training and head injury policies, with no written guidance for ambulance summoning, raising …	North West Manchester (South)	Peaks and Plains Housing Trust	0/1