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 274 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
14 May 2015	Steven Bottomley 2015-0186 · Martin Fleming A window lacked a safety device, and remedial action is required to safeguard similar windows in properties to prevent recurrence in line …	Yorkshire and the Humber West Yorkshire (West)	No addressees parsed	0/0
13 May 2015	Paul Murray 2015-0193 · Andrew Walker Insufficient resources were available for the London Ambulance Service to meet demand on the day of the incident.	London London (North)	Department of Health and Social …	1/1
13 May 2015	Hana Elhamid 2015-0194 · Andrew Walker Lack of routine blood tests for sugar in a patient on Clozapine treatment led to an undiagnosed diabetic coma, with resultant trachea …	London London (North)	Department of Health and Social …	1/1
13 May 2015	Fred Hudson 2015-0188 · Melanie Williamson A disused railway bridge is easily accessible to the public, including children, and no steps have been taken to prevent access despite …	Yorkshire and the Humber West Yorkshire (East)	Highways England Historical Railways Estate	0/2
13 May 2015	Paul Littlewood 2015-0187 · Julian Fox Gantry safety barriers were too low, lacked an intermediate crossbar and toe-plate, and fall protection at the access ladder was inadequate, creating …	Yorkshire and the Humber South Yorkshire (West)	Steadplan Ltd Freight Transport Association Ltd Road Haulage Association	1/3
12 May 2015	Paul McGuigan 2015-0185 · Joanne Kearsley General concerns were raised across relevant agencies about risks that could lead to future deaths, requiring action.	North West Manchester (South)	Greater Manchester Police Home Office Ministry of Defence Ministry of Justice	3/8
11 May 2015	John Lobo 2015-0182 · Selena Lynch Assessing fitness to travel for direct repatriation requires medical expertise beyond a paramedic, and independent medical assessment should be considered in such …	London London (South)	Exora Medical Limited	1/1
11 May 2015	Keith Gallimore 2015-0184 · R Brittain Potentially important patient information documented by one service was not accessible to other services within the same Trust, especially out-of-hours, risking future …	London London Inner (North)	Camden and Islington NHS Foundation …	1/1
11 May 2015	Margaret Wright 2015-0183 · Jennifer Leeming Doctors did not routinely telephone patients or families after home visit requests to obtain further information, potentially delaying priority visits and impacting …	North West Manchester (West)	Department of Health and Social …	1/1
11 May 2015	Lydia Corah 2015-0181 · Stephanie Haskey An error led to a patient undergoing an X-ray intended for another, causing delay in assessment, unnecessary radiation, and adversely affecting the …	East Midlands Nottinghamshire	Nottingham University Hospitals NHS Trust	1/1
11 May 2015	Chandni Nigam 2015-0180 · Peter Bedford No attempt was made to obtain historical input or information from private clinicians when the patient reverted to NHS mental health care, …	South East Berkshire	Berkshire Healthcare NHS Foundation Trust	0/1
8 May 2015	Thaker Hafid 2015-0192 · Andrew Barkley The free availability and high potency/toxicity of the unlicensed 'designer drug' Acetylfentanyl, sold over the internet, poses a significant risk of future …	Wales Cardiff & the Vale of Glamorgan	Advisory Council for the Misuse …	0/1
8 May 2015	Michael Hacker 2015-0179 · Maria Voisin Concerns were raised regarding the ambulance service policy around the Mental Capacity Act, specifically regarding restraint or force if a patient lacks …	South West Avon	South Western Ambulance Service	0/1
7 May 2015	Evelyn Kennedy 2015-0178 · Veronica Hamilton-Deeley Acute Medical Unit failed significantly in patient care, with issues including incomplete handovers, poor personal hygiene, missing wristbands, unremoved IVs, incomplete care …	South East Brighton & Hove	Brighton and Sussex University Hospitals …	1/1
7 May 2015	Baby Olsberg 2015-0177 · Lisa Hashmi Antenatal screening for Group B Streptococcus (GBS) and prophylactic intrapartum antibiotics for positive cases are not routinely offered by the NHS, potentially …	North West Manchester (North)	Department of Health and Social … National Institute for Health and … Royal College of Obstetricians Royal College of Paediatricians	3/4
1 May 2015	Jayne Jowett 2015-0175 · Elizabeth Didcock PIC staff lack adequate training in interpreting and escalating National Early Warning Scores, and struggle to understand critical clinical signs. There's no …	East Midlands Nottinghamshire	Annesley Woodhouse Partnerships In Care	1/2
1 May 2015	Julios Catachanas 2015-0174 · S McGovern The absence of street lighting at a junction, combined with the layout allowing vehicles to drive 'straight through', creates a significant road …	West Midlands Warwickshire	Warwickshire County Council	1/1
1 May 2015	Derrick Stanmore 2015-0172 · Lydia Brown A registered nurse failed to recognise abnormal patient observations requiring escalation, and lacked access to essential healthcare records to contextualise findings. A …	East Midlands Leicester (City & South)	Leicester Partnership Trust	1/1
29 Apr 2015	Finnulla Martin 2015-0173 · ME Hassell The psychiatry liaison team at Whittington Hospital appeared unclear on protocols for receiving information from police officers bringing patients in voluntarily, and …	London London North (Inner)	Camden and Islington NHS Foundation … Metropolitan Police Service Whittington Hospital NHS Trust	0/3
29 Apr 2015	Jorge Castro 2015-0170 · Alan Walsh A vulnerable patient missed crucial anti-epileptic medication due to uncollected prescriptions, which GPs failed to review during multiple consultations. The surgery lacked …	North West Manchester (West)	Springfield Medical Practice	1/1