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 272 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
22 Jun 2015	Kian Gill 2015-0235 · Catherine Mason Highway safety is compromised by overgrown hedgerows obscuring junction visibility, a lack of warning signage, and an uncurtailed national speed limit, creating …	East Midlands Leicester City and South Leicestershire	Leicestershire County Council	1/1
19 Jun 2015	Elizabeth Godwin 2015-0233 · Ian Singleton Critical issues exist in mental health care regarding incomplete information gathering for assessments, poor urgency monitoring, inadequate inter-agency communication, unclear care responsibilities, …	South West Wiltshire and Swindon	Avon and Wiltshire NHS Mental … Royal United Hospitals Bath NHS … Wiltshire Council	3/3
18 Jun 2015	John Bartle 2015-0232 · Margaret Jones Concerns were raised about a perceived lack of staff over a bank holiday leading to delayed interventions, alongside poor nutritional support, inadequate …	West Midlands Stoke-on-Trent and North Staffordshire	am Margaret CORONER Jones, Assistant Coroner, for Stoke-on-Trent …	0/3
17 Jun 2015	Andre Mickley 2015-0231 · ARW Forrest Product information for SSRI drugs fails to adequately inform prescribers about potential adverse pharmacokinetic interactions with cocaine and other illicit substances, or …	East Midlands Lincolnshire (Central)	Medicines and Healthcare products Regulatory …	0/1
17 Jun 2015	Andrew Nickolls 2015-0230 · Ian Arrow The provided text is incomplete and does not contain any discernible coroner's concerns.	South West Plymouth, Torbay and South Devon	Devon County Council Northern Eastern and Western Devon … Plymouth City Council Torbay and South Devon Clinical …	0/5
15 Jun 2015	Isaac Bahar 2015-0229 · Veronica Hamilton-Deeley A patient with advanced kidney disease was fatally prescribed Codeine, directly breaching hospital policy and national guidance on medication for vulnerable patients.	South East Brighton and Hove	Brighton and Sussex University Hospitals …	1/1
12 Jun 2015	Marie Harding 2015-0214 · Martin Fleming The trust lacked clear guidelines and up-to-date staff training for chest drain insertion, compounded by an unawareness of interventional radiologist availability, indicating …	Yorkshire and the Humber West Yorkshire (West)	NHS England	0/1
12 Jun 2015	Sidney Barnett 2015-0222 · John Pollard The care home provided inadequate observation and general welfare for the client, and the subsequent safeguarding investigation was flawed, relying too heavily …	North West Manchester (South)	Berrycroft Manor Care Home Stockport Metropolitan Borough Council	1/2
12 Jun 2015	Nancy Hughes 2015-0221 · John Gittins No systematic medication review occurred as per medical practice, and a lack of cohesion between mental health and general medical treatment meant …	Wales North Wales (East & Central)	BCUHB, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, …	1/1
11 Jun 2015	Deborah Roberts Patricia Harding The Sheppey Road Bridge has a history of rear-end collisions due to its geometry affecting visibility and high speeds. Despite a safety …	South East Mid Kent & Medway	National Highways	1/1
10 Jun 2015	Amanda Harris 2015-0216 · Andrew Walker Mrs Harris was discharged from the Minor Injuries Unit without a doctor's review, consideration of anticoagulant therapy, or assessment of potential immobility …	London London (North)	Mount Vernon Hospital	0/1
10 Jun 2015	Arti Lakhani 2015-0217 · Andrew Walker Concerns were raised about the lack of regulation and licensing for the sale of e-cigarette fluid.	London London (North)	Department of Health and Social …	1/1
10 Jun 2015	Walter Willows 2015-0218 · John Pollard Care plans, especially feeding regimes, were reviewed insufficiently frequently for clients with changing needs, specifically regarding swallowing ability, leading to inadequate dietary …	North West Manchester (South)	Westwood Homecare Limited	0/1
10 Jun 2015	Darren Neville 2015-0220 · ME Hassell Police officers did not adequately consider the significant risk of death associated with prolonged restraint for individuals experiencing acute behavioural disturbance.	London London Inner (North)	Metropolitan Police Service	1/1
9 Jun 2015	Lewis Ghessen 2015-0213 · Andrew Walker The RSSB Rule Book is flawed as it only permits stopping trains to prevent damage, not to protect individuals in danger from …	London London (North)	Rail Safety and Standards Board	0/1
4 Jun 2015	Christopher Tandy 2015-0234 · Roy Palmer Inadequate signage and road layout on London Bridge encourage speeding, with insufficient prominent 20 mph speed limit signs and a lack of …	London London (City)	for information) Transport for London	1/2
4 Jun 2015	Alice McMeekin 2015-0211 · David Roberts Police failed to act on reported threats and share critical information with mental health services, leading to a flawed psychiatric assessment and …	North West Cumbria	Cumbria Constabulary Cumbria Partnership NHS Foundation Trust	0/2
3 Jun 2015	Frederick White 2015-0212 · Zafar Siddique There was a significant delay in diagnosing and managing a suspected spinal cord injury, including an initial failure to immobilise the patient …	West Midlands Black Country	Care Quality Commission Dudley Group NHS Foundation Trust West Midlands Ambulance Service NHS …	1/3
1 Jun 2015	David Price 2015-0210 · John Pollard Problems included uncontrolled warfarin prescriptions without clinic attendance, very poor quality handwritten medical notes, failure to act on a radiologist's finding of …	North West Manchester (South)	Department of Health and Social … University Hospital of South Manchester	0/2
1 Jun 2015	James Savo 2015-0209 · Nicola Mundy Effective communication systems between families/carers and staff are not routinely followed or audited, and understanding of early discharge plans is inconsistent, hindering …	Yorkshire and the Humber South Yorkshire (East)	Rotherham, Doncaster and South Humber …	0/1