Report dated 4 Sep 2015
Added from Judiciary.uk 4 Aug 2015
Coroner: Sarah-Jane Richards
Wales
Powys
AI-generated concerns summaryThe coroner noted inadequate monitoring of INR levels and uncertainty regarding Warfarin adherence for a patient with dementia. There were also concerns about communication gaps between the INR Unit, care home, and GP, and a missed opportunity for hospital admission to adjust anticoagulation therapy.
Addressed to: Bryntirion Surgery; Care & Social Services Inspectorate, Welsh Government Office; Aneurin Bevin University Health Board; Cwm Taf Morgannwg University Health Board; Brindaven Care Home Limited; HM Chief Coroner; Aneurin Bevin University Health Board; National Assembly for Wales
0 responses identified · 8 indexed addressees. Read concerns and response evidence →
Report dated 4 Aug 2015
Added from Judiciary.uk 4 Aug 2015
Reference 2015-0307
Coroner: Bridget Dolan
South East
West Sussex
AI-generated concerns summaryThe coroner identified a lack of formal case review by local authorities, a hazardous electric fire left in a home, and social work staff's insufficient training and awareness regarding criteria for requesting police welfare checks.
Addressed to: Crawley Borough Council; West Sussex County Social Services
1 response identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 3 Aug 2015
Added from Judiciary.uk 3 Aug 2015
Reference 2015-0304
Coroner: Peter Bedford
South East
Berkshire
AI-generated concerns summaryThe coroner notes confusion regarding appropriate pre-operative blood glucose levels for surgical patients, as the hospital's policy differed from national guidelines and published research. The Trust is asked to review its recommended levels.
Addressed to: other private hospitals that utilise similar policies; Royal Berkshire Hospital Trust
0 responses identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 30 Jul 2015
Added from Judiciary.uk 30 Jul 2015
Reference 2015-0249
Coroner: Andrew Walker
London
London (North)
AI-generated concerns summaryInsufficient guidance for trusts was identified regarding the general management of long-term tracheostomy patients with complex medical needs.
Addressed to: Department of Health and Social Care
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 30 Jul 2015
Added from Judiciary.uk 30 Jul 2015
Reference 2015-0305
Coroner: Thomas Osborne
East of England
Bedfordshire and Luton
AI-generated concerns summaryThe coroner noted inappropriate midwifery care by a student midwife, including insufficient fetal monitoring and CTG misinterpretation, alongside a failure to escalate care. This raised questions about Bedford Hospital's suitability as a clinical learning environment.
Addressed to: Health Education East of England; LET Board
1 response identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 30 Jul 2015
Added from Judiciary.uk 30 Jul 2015
Reference 2015-0303
Coroner: Joseph Turner
South East
West Sussex
AI-generated concerns summaryConcerns are raised that front blind spot mirrors on high-fronted goods vehicles provide insufficient visibility for pedestrians, particularly those close to the vehicle, and there is an over-reliance on them due to an absence of secondary front obstruction warning systems.
Addressed to: Department for Transport
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 28 Jul 2015
Added from Judiciary.uk 28 Jul 2015
Reference 2015-0301
Coroner: 2015-0301
Yorkshire and the Humber
South Yorkshire (East)
AI-generated concerns summaryThere were no protocols or guidance for primary care providers on monitoring patients prescribed Amiodarone for liver, thyroid, and respiratory functions. The coroner also noted insufficient monitoring by prescribers during the initial 12 months when toxicity commonly develops.
Addressed to: Northern General Hospital
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 27 Jul 2015
Added from Judiciary.uk 27 Jul 2015
Reference 2015-0300
Coroner: Sarah-Jane Richards
Wales
Powys, Bridgend and Glamorgan
AI-generated concerns summaryThe coroner identified low staffing levels for Tissue Viability Nurses, inadequate pressure ulcer documentation and repositioning charts, and a lack of integrated skin care within and between health boards and primary healthcare services.
Addressed to: Aneurin Bevan University Health Board; Bryntirion Surgery; Cwm Taf University Health Board; Four Season’s Healthcare Home; National Assembly for Wales
0 responses identified · 5 indexed addressees. Read concerns and response evidence →
Report dated 24 Jul 2015
Added from Judiciary.uk 24 Jul 2015
Reference 2015-0296
Coroner: Maria Voisin
South West
Avon
AI-generated concerns summaryThe coroner identified a lack of documented risk assessment upon service user admission to Mason Unit, and insufficient guidance and training for staff on setting observation levels, assessing and managing suicide/self-harm risk, and communicating that risk.
Addressed to: Avon and Wiltshire Mental Health NHS Trust
0 responses identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 24 Jul 2015
Added from Judiciary.uk 24 Jul 2015
Reference 2015-0298
Coroner: Elizabeth Earland
South West
Exeter and Greater Devon
AI-generated concerns summaryThe quality of custodial and welfare checks for a prisoner on an ACCT and Methadone Stabilisation Programme were insufficient, and information sharing regarding these checks appeared deficient.
Addressed to: Dorset Health Care University NHS Foundation Trust; HMP Exeter
1 response identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 23 Jul 2015
Added from Judiciary.uk 23 Jul 2015
Reference 2015-0295
Coroner: ARW Forrest
East Midlands
South Lincolnshire
AI-generated concerns summaryThe coroner raised concerns regarding whether current guidance on co-prescribing ACE inhibitors and Spironolactone sufficiently emphasizes the need for caution, patient monitoring, and a holistic approach, given known risks such as hyperkalaemia.
Addressed to: Lincolnshire Community Health Services; Medicines and Healthcare products Regulatory Agency; National Institute for Health and Care Excellence
0 responses identified · 3 indexed addressees. Read concerns and response evidence →
Report dated 23 Jul 2015
Added from Judiciary.uk 23 Jul 2015
Reference 2015-0297
Coroner: David Urpeth
West Midlands
Black Country
AI-generated concerns summaryThe coroner noted insecure fencing allowed access to the site, with some perimeter fencing secured by cable ties, and that family members could access the site unchallenged after the death. Additionally, there were no warning signs on Bridge 26 about the dangers of high voltage cabling.
Addressed to: British Transport Police
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 23 Jul 2015
Added from Judiciary.uk 23 Jul 2015
Reference 2015-0294
Coroner: Philip Sharp
North West
Cumbria
AI-generated concerns summaryThe coroner noted concerns regarding the efficacy of the boat's entry system for crew returning after 10 pm. There were also issues with the recording and monitoring of crew working hours, which may have led to tiredness from additional shifts.
Addressed to: Plateus Ltd
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 23 Jul 2015
Added from Judiciary.uk 23 Jul 2015
Reference 2015-0291
Coroner: Louise Hunt
West Midlands
Birmingham and Solihull
AI-generated concerns summaryThe coroner identified a lack of care plans for high-risk patients, insufficient staff knowledge and training regarding pressure sore prevention, and gaps in ward leadership and medical cover.
Addressed to: Birmingham and Solihull Mental Health Trust; Department of Health and Social Care; NHS England
1 response identified · 3 indexed addressees. Read concerns and response evidence →
Report dated 22 Jul 2015
Added from Judiciary.uk 22 Jul 2015
Reference 2015-0506
Coroner: Andrew Cox
West Midlands
Worcestershire
AI-generated concerns summaryThe coroner noted an undulation in the road surface that likely caused a vehicle to lose control, particularly at higher speeds, posing a risk of collision for drivers.
Addressed to: Worcestershire County Council
0 responses identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 21 Jul 2015
Added from Judiciary.uk 21 Jul 2015
Reference 2015-0293
Coroner: Sonia Hayes
London
London (South)
AI-generated concerns summaryThe coroner noted gaps in the Metropolitan Police Service's welfare check policy, including insufficient training for staff, lack of communication with the London Ambulance Service and GPs, and a failure to inform a GP when a welfare check request was downgraded.
Addressed to: London Ambulance Service; Metropolitan Police
1 response identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 21 Jul 2015
Added from Judiciary.uk 21 Jul 2015
Reference 2015-0288
Coroner: Wendy James
Wales
Gwent
AI-generated concerns summaryMedical staff and porters were unaware of or did not follow Health Board protocols, and the major obstetric haemorrhage protocol did not align with Royal College guidelines.
Addressed to: Aneurin Bevan University Health Board
0 responses identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 20 Jul 2015
Added from Judiciary.uk 20 Jul 2015
Reference 2015-0285
Coroner: Grahame Short
South East
Hampshire (Central)
AI-generated concerns summaryA 16-year-old marshall was positioned contrary to club rules, used a mobile phone, and faced away from riders, delaying warning flag deployment. The coroner also noted a lack of guidance in the MCF Code of Practice regarding smartphone use by marshalls.
Addressed to: M C Federation; Portsmouth Motocross Club
1 response identified · 2 indexed addressees. Read concerns and response evidence →
Report dated 20 Jul 2015
Added from Judiciary.uk 20 Jul 2015
Reference 2015-0292
Coroner: Andre Rebello
North West
Liverpool
AI-generated concerns summaryHMP Liverpool miscalculated a prisoner's extended sentence, which was a likely factor in their death, and the coroner questions if other prisoners sentenced during that period might also have incorrect sentences. Additionally, two prison discipline staff members had significantly outdated first aid training.
Addressed to: National Offenders Management Service
1 response identified · 1 indexed addressee. Read concerns and response evidence →
Report dated 20 Jul 2015
Added from Judiciary.uk 20 Jul 2015
Reference 2015-0286
Coroner: Karen Dilks
North East
Newcastle Upon Tyne
AI-generated concerns summaryThe coroner raised concerns regarding the lack of illuminated signage for pedestrians on a complex slip road and impaired driver visibility of hazards due to limited sightlines, particularly given the 50 mph speed limit.
Addressed to: Gateshead Council
1 response identified · 1 indexed addressee. Read concerns and response evidence →