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.
Reports
| Date | Report | Responses identified |
|---|---|---|
| 29 Apr 2015 |
Doreen Wood
2015-0169 · Heidi Connor
Concerns exist regarding the unreliability of INR monitoring systems, including reliance on healthcare assistants for critical clinical information instead of standard protocols. …
|
0/2 |
| 29 Apr 2015 |
Rasharn Williams
2015-0168 · ME Hassell
The patient's care plan was unclear regarding emergency actions for breathlessness, potentially causing ambiguity for staff. A vital medical instruction notice for …
|
1/1 |
| 29 Apr 2015 |
Barry Wilson
2015-0167 · Pritchard Jones
A defective surgical anastomosis, made with staples, was not detected prior to the patient's hospital discharge, directly contributing to their death.
|
1/1 |
| 28 Apr 2015 |
Martyn Horton, David Ramsden, Douglas Halliday and Alexander Isaac
2015-0164 · David Ridley
The Ridgeback vehicle, introduced for operational service, has unspecified "suspension issues" that raise concerns for safety.
|
1/1 |
| 28 Apr 2015 |
Rita Paton
2015-0166 · R Brittain
There's no reliable system to ensure blood tests are completed and reported to GPs, or for managing appointments for patients lacking capacity …
|
0/1 |
| 28 Apr 2015 |
Greg Revell
2015-0165 · Lydia Brown
Ineffective suicide prevention measures were evident, with a prisoner not placed on ACCT despite clear risk and a culture of avoiding such …
|
2/2 |
| 27 Apr 2015 |
Sally Ellison
2015-0163 · John Gittins
There was a significant delay in conducting diagnostic tests for severe pneumonia, specifically Legionella, hindering confirmed diagnosis and potentially delaying optimal treatment. …
|
1/1 |
| 27 Apr 2015 |
Tamara Holboll
2015-0171 · ME Hassell
The trust lacks precise definitions for "good communication," failing to specify exactly what information, by whom, when, and how it should be …
|
1/1 |
| 27 Apr 2015 |
Joshua Brown
2015-0162 · Richard Travers
National police driver training for night-time operations lacks a compulsory practical in-car element, potentially compromising officer safety and response effectiveness.
|
1/2 |
| 24 Apr 2015 |
Hilda Harris
2015-0161 · Sarah-Jane Richards
The community INR testing booking system is unreliable due to failures in appointment transfer and an unreliable notification system for omissions by …
|
1/2 |
| 23 Apr 2015 |
Efan James
2015-0158 · Jonathan Layton
The Welsh Assembly Government's advice on reducing cot death is confusing, specifically regarding the ambiguous "very tired" criterion for parents considering bed-sharing.
|
1/1 |
| 23 Apr 2015 |
Patricia Chapman
2015-0159 · Andrew Tweddle
Revised training for community hospital staff lacks provision for obtaining emergency expert medical advice from acute hospitals, potentially delaying critical guidance in …
|
1/1 |
| 22 Apr 2015 |
Laurence Boyens
2015-0156 · Andrew Harris
Healthcare professionals appeared to misunderstand guidelines for managing drug dependence in adult prison settings, particularly around monitoring blood pressure before administering methadone …
|
2/5 |
| 22 Apr 2015 |
Noel Jones
2015-0155 · Geraint Williams
Delays in patient acceptance by the hospital and the absence of out-of-hours vascular surgery or interventional radiology services likely contributed to the …
|
1/1 |
| 22 Apr 2015 |
Jack Rowe
2015-0154 · Claire Balysz
The absence of compulsory child-resistant fencing for private swimming pools in the UK, unlike other countries, creates a significant drowning risk for …
|
1/2 |
| 22 Apr 2015 |
Eliza Bowen
2015-0160 · Zafar Siddique
A patient with complex needs and known risk factors developed diabetic ketoacidosis, but critical blood glucose monitoring ceased in 2014, missing indications …
|
0/2 |
| 21 Apr 2015 |
Willow Davies
2015-0157 · Thomas Osborne
An inexperienced midwife was unsupported during delivery without prior resuscitation training, highlighting flaws in midwife allocation and the 'Supervisors of Midwives' support …
|
1/1 |
| 21 Apr 2015 |
Anthony Garrett
2015-0153 · Rachael Griffin
Readily available and misused synthetic cannabinoids, despite warnings, are dangerous and caused a fatal cardiac event. Concerns were raised about their legal …
|
0/3 |
| 21 Apr 2015 |
Howell Fisher
2015-0152 · Andrew Barkley
Insufficient staff led to multiple falls for a high-risk patient. There was a critical lack of falls risk assessment and handover information …
|
0/2 |
| 21 Apr 2015 |
Bruce Longden
2015-0149 · Veronica Hamilton-Deeley
The Sussex Partnership Trust demonstrated a critical lack of awareness regarding its own internal protocols.
|
1/2 |