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 273 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
1 Jun 2015	Mark Daniels 2015-0208 · ME Hassell The crisis team failed to conduct planned patient visits, adequately record actions, communicate within the team, promptly refer to crisis houses, or …	London London Inner (North)	Camden and Islington NHS Foundation …	1/1
1 Jun 2015	Ronald Smith 2015-0207 · Nadia Persaud There was a failure to provide flexible sigmoidoscopy out of hours, and despite a root cause analysis identifying the need for a …	London London (East)	Barking, Havering and Redbridge University …	0/1
1 Jun 2015	Mark Foley 2015-0204 · Philip Sharp Driver inexperience and the commander's failure to wear a safety harness, due to permitted discretion and lax enforcement of standing orders, led …	North West Cumbria	Minister of Defence British Army the suppliers of the software	1/3
29 May 2015	Elizabeth Lester 2015-0204-wp24868 · John Pollard The ambulance service's call-handler script for 'breathing difficulties' critically omits questions about chest pain, potentially delaying appropriate emergency response for cardiac-related issues.	North West Manchester (South)	Department of Health and Social …	1/1
29 May 2015	Melanie Amundsen 2015-0206 · Derek Winter Not all employers or employees may be aware of mental health issues in the workplace, particularly concerning disciplinary processes, and ACAS resources …	North East Sunderland	Advisory, Conciliation and Arbitration Service	0/1
29 May 2015	Alison Draper 2015-0205 · Maria Voisin A policy gap exists for managing patients not found within 10-minute observation periods, and guidance is needed for staff balancing hourly checks …	South West Avon	Avon and Wiltshire NHS Partnership …	0/1
27 May 2015	Yusuf Abdismad 2015-0202 · ME Hassell Emergency medical dispatchers use confusing questioning to ascertain consciousness, leading to misinterpretation of patient status and missing critical symptoms like a rash …	London London Inner (North)	London Ambulance Service NHS Trust	0/1
27 May 2015	Nicholas Stocks 2015-0200 · Mary Burke Police failed to fully report road traffic collision concerns to the council, and there are inadequate systems for risk assessment and urgent …	Yorkshire and the Humber West Yorkshire (West)	Kirklees Council West Yorkshire Police	1/2
27 May 2015	Matthew Hoare 2015-0203 · Lorna Tagliavini Ineffective security equipment allowed easy access to the station and tracks after operational hours, with individuals able to climb through widely spaced …	London London (Inner South)	National Rail	1/1
27 May 2015	Oliver Asante-Yeboah 2015-0201 · R Brittain Concerns were raised about the lack of formal regulation for non-medical providers of circumcision, a procedure considered surgical with increased infection risk …	London London Inner (North)	Care Quality Commission	2/1
22 May 2015	Olive Darbyshire Alan Wilson An urgent CTPA procedure was delayed and miscategorised, exacerbated by a lack of follow-up from the clinical team, radiology department errors, and …	North West Blackpool and The Fylde	Blackpool Teaching Hospital NHS Foundation …	1/1
21 May 2015	Barbara Patterson 2015-0198 · Carly Henley The Pathways system has a fault preventing timely CPR advice for agonal breathing, and ambulance dispatch was delayed due to paramedic shortages …	North East Northumberland (North)	Care Quality Commission Department of Health and Social … North East Ambulance Service NHS …	3/3
20 May 2015	Wanda Stachurska 2015-0199 · Bridget Dolan Mental health risk assessments were diminished by untrained interpreters and staff unaware of policies. Furthermore, a serious incident review was not undertaken, …	South East West Sussex	Surrey and Borders Partnership NHS … Surrey and Sussex Healthcare NHS …	1/2
20 May 2015	Irene Hamilton-Parker 2015-0197 · Andrew Haigh Clothing made of easily flammable man-made fabrics poses a risk, and steps should be considered to reduce the flammability of manufactured or …	West Midlands Staffordshire (South)	Department of Business Innovation and …	1/1
20 May 2015	Viola Burke 2015-0196 · Jacqueline Devonish The GP practice failed to inquire about the reason for asthma pump use, and an incomplete care plan system for vulnerable patients …	London London Inner (North)	City and Hackney GP Confederation Lawson Practice	1/2
19 May 2015	Sheila Johnson 2015-0238 · Robert Hunter The internal investigation into the death was perfunctory, lacked robust inquiry, missed key interviews, and contained factual inaccuracies, risking future patient harm.	East Midlands Derby and Derbyshire	Tameside Hospital NHS Foundation Trust	2/1
18 May 2015	Diana Hughes 2015-0195 · Katy Skerrett Concerns relate to the communication of 'special instructions' to medical personnel during surgical procedures via the WHO/Surgical checklist.	South West Gloucestershire	Not Listed	1/1
15 May 2015	Jacques Lakeman and Torin Lakeman 2015-0191 · Alan Walsh Easy access to anonymous 'Dark Web' sites for unregulated illicit drugs with unknown potency and content poses a significant and ongoing risk …	North West Manchester (West)	Home Office	1/1
15 May 2015	Sara Green 2015-0190 · Andrew Bridgman Delays of up to 24 hours in 'writing up' medical consultations risk important information being unavailable or misinterpreted, potentially harming patients.	North West Manchester (South)	Priory Group	1/1
15 May 2015	George Richardson 2015-0189 · Derek Winter Lack of a consolidated catheterisation record meant staff were unaware of previous challenges, and national standards may be needed for safe catheterisation …	North East Sunderland	Department of Health and Social …	1/1