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 276 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
21 Apr 2015	Mary Hanson 2015-0148 · Claire Hammond There was inadequate documentation of the risks and benefits of pituitary surgery discussed with the patient, missing information on capacity and best …	North West Preston and West Lancashire	Lancashire Teaching Hospital	0/1
20 Apr 2015	Andrew Farrow 2015-0147 · Peter Hatvany A patient with suicidal ideation who requested admission could not be accommodated due to a lack of available beds at the mental …	South West Wiltshire & Swindon	Avon and Wiltshire Mental Health … Department of Health and Social …	1/2
20 Apr 2015	Daniel Hodgin 2015-0146 · John Ellery A crucial towpath gate, intended to be locked during high river levels, was open due to the absence of an effective notification …	West Midlands Shropshire, Telford & Wrekin	Senior Lawyer Professional Support Legal Services, Warrington Shropshire Council	2/3
17 Apr 2015	Patrick Sturtivant 2015-0144 · David Ridley Public parking on a Byway adjacent to a main road for Stonehenge viewing creates a significant road safety risk. Concerns were raised …	South West Wiltshire & Swindon	Department for Transport English Heritage National Trust Wiltshire Council	3/5
17 Apr 2015	Robert Watt 2015-0145 · Patricia Harding Crucial information about clinic attendance and referrals was not communicated or documented. Junior doctors handled specialist consultations, and a urologist failed to …	South East Mid Kent & Medway	Medway NHS Foundation Trust	0/1
17 Apr 2015	Mark Groombridge 2015-0142 · Andrew Haigh There was no direct communication between the local offender manager and the clinician responsible for the patient's care before the recall paperwork …	West Midlands Staffordshire (South)	HM Prison and Probation Service	1/1
16 Apr 2015	Kesia Leatherbarrow 2015-0143 · Joanne Kearsley Critical communication failures and incomplete information sharing between Children's Services and CAMHS across different regions, along with a failure to transfer the …	North West Manchester (South)	Crown Prosecution Service Department of Health and Social … Greater Manchester Police Home Office	4/11
16 Apr 2015	Robert Payne 2015-0140 · Andrew Barkley Repeated falls for a high-risk patient, leading to further surgery, highlighted inadequate fall prevention. An early morning ward transfer lacked documentation, and …	Wales Powys, Bridgend & Glamorgan Valleys	Abertawe Bro Morgannwg University Health … Health Inspectorate Wales	0/2
16 Apr 2015	Jeanne Summers 2015-0139 · Mary Burke Inadequate discharge assessment, incomplete physiotherapy records, and unsafe patient mobilization practices, including inappropriate footwear and unsupervised transfers, contributed to a fall. The …	Yorkshire and the Humber West Yorkshire (West)	Calderdale and Huddersfield NHS Foundation …	0/1
16 Apr 2015	Maurice Camfield 2015-0176 · David Hinchliff Crucial one-to-one nursing care, stipulated in the agreed care plan, was not consistently provided to the patient.	Yorkshire and the Humber West Yorkshire (East)	Mid Yorkshire Hospitals NHS Trust	0/1
15 Apr 2015	Stephen Myers 2015-0150 · J Hamilton A product containing isopropyl nitrite, misused by inhalation, has inadequate labelling that fails to comply with current safety regulations (CLP) regarding hazards …	North East County Durham & Darlington	Department of Business, Innovations and … General Product Safety Department	1/2
15 Apr 2015	Nicholas Rowley 2015-0138 · Ian Smith Insufficient verbal consultation between medical practitioners and custody staff, coupled with inadequate joint training, led to unclear observation levels and poor management …	West Midlands Stoke-on-Trent & North Staffordshire	Department of Health and Social … G4S National Police Chiefs’ Council Nestor Primecare	3/5
13 Apr 2015	Austen Harrison 2015-0481 · Darren Salter Basic health and safety training for managers, coupled with a lack of understanding of responsibilities and infrequent professional audits, led to undetected …	South East Oxfordshire	Hugo Boss UK	1/1
13 Apr 2015	Hayden Norton 2015-0137 · Elizabeth Earland After the deceased arrived at HMP Dartmoor, there was no record that his blood pressure was monitored, or that he had been …	South West Exeter & Greater Devon	Dorset Healthcare University NHS Foundation … NHS England	1/2
8 Apr 2015	Aleysha McLoughlin 2015-0136 · Jennifer Leeming The training system for professionals working with young people regarding self-harm requires a comprehensive review, as self-harm is a growing public health …	North West Manchester (West)	Department for Education Department of Health and Social … Ministry of Housing, Communities & …	1/3
8 Apr 2015	Daniel Foss 2015-0062 · Colin Phillips A serious design flaw on the Kingsway/Metro system has led to over 100 road traffic incidents, including injuries and two fatalities, involving …	Wales Swansea Neath & Port Talbot	Swansea Council	1/1
1 Apr 2015	Christopher Watson 2015-0133 · Jacqueline Lake Social care failed to ensure a vulnerable individual received, understood, or could read a letter offering help, and did not make direct …	East of England Norfolk	Norfolk County Council	1/1
1 Apr 2015	John Lowe 2015-0132 · Stephanie Haskey Nursing staff incorrectly believed 1:1 care could not be provided for falls risk alone, only for mental health needs, regardless of a …	East Midlands Nottinghamshire	Nottinghamshire Healthcare NHS Trust	0/1
31 Mar 2015	Olive Nugent 2015-0134 · Karen Dilks Falls activator device responses were delayed due to subjective prioritisation and insufficient staffing, particularly for non-verbal users, leaving vulnerable individuals without timely …	North East Newcastle Upon Tyne	South Tyneside Council	0/1
31 Mar 2015	Thomas Beaty 2015-0130 · Lisa Hashmi Guidance on instrumental delivery was ambiguous and potentially open to misinterpretation, lacked operational definitions for terms like 'imminent', and the term 'gentle' …	North West Manchester (North)	Department of Health and Social … Pennine Acute Hospitals NHS Trust Royal College of Obstetricians and …	2/3