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.

Response tracker Organisations Advanced search

Keyword

Browse by year

Browse by region

Sort

Reports

6,383 reports · Page 277 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
31 Mar 2015	Sharon Butcher 2015-0129 · Andrew Tweddle There was a delay in calling for an ambulance after an emergency medical code was broadcast, and a recurring issue of lack …	North East County Durham & Darlington	HMP Frankland National Offender Management Service	1/2
30 Mar 2015	Kenneth Williams 2015-0135 · Simon Wickens Inadequate review of patient history and imaging before invasive procedures, insufficient respiratory consultant input, and poor communication between medical teams increased risks. …	South East Surrey	Epsom and St Helier University …	1/1
30 Mar 2015	Jason Houghton 2015-0127 · Alan Walsh The unregulated online supply and international importation of Class A drugs, specifically Diacetyl Morphine/Heroin in pill form via postal systems, poses a …	North West Manchester (West)	Home Office	1/1
30 Mar 2015	Sabrina Stevenson 2015-0126 · R Brittain Worsening ambulance response times, staffing shortages, unaddressed training issues (e.g., pregnancy testing, extraction), and a lack of system improvements like automated re-categorisation …	London London North (Inner)	College of Paramedics London Ambulance Service NHS Trust NHS England	3/3
30 Mar 2015	Andrea Thirkell 2015-0124 · Andrew Tweddle Lack of formal monitoring for patients awaiting discharge and an absence of clear policy for safe late-night discharges risk inconsistent, potentially erroneous …	North East County Durham & Darlington	Darlington Memorial Hospital	0/1
30 Mar 2015	Kelly Willis 2015-0122 · Rachel Redman Failure to timely liaise with a tertiary care center regarding a patient's complex medical history and specific requests delayed critical investigations, missing …	South East Kent (Central & South East)	East Kent Hospitals University NHS …	1/1
25 Mar 2015	Bryan Whitby 2015-0121 · Joanne Kearsley The provided text is incomplete and does not contain any discernible coroner's concerns.	North West Manchester (South)	Central Manchester University Hospitals Trust Davyhulme Medical Centre	2/2
25 Mar 2015	Keith Murphy 2015-0120 · Simon Wickens Prison staff lack basic first aid, CPR, and defibrillator training, and healthcare provision is unavailable outside limited hours, leaving prisoners vulnerable to …	South East Surrey	National Offender Management Service NHS England	1/2
25 Mar 2015	Harold Ambrose 2015-0118 · Eleanor McGann There is no requirement for GPs or Mental Health Trusts to notify police about mental health concerns for firearm licence holders, and …	East of England Essex	Home Office	0/1
24 Mar 2015	Stuart Baumber 2015-0116 · David Heming Many prison cell doors lack anti-ligature strips due to an absent retrofit program. Furthermore, the ACCT process lacks a structured national pro …	East of England Peterborough	National Offender Management Service Sodexo Justice Services	0/2
24 Mar 2015	Michael Richardson 2015-0114 · David Osborne Critical information from ambulance reports, such as a patient's nutritional status, was not adequately reviewed during hospital admission, risking adverse outcomes if …	East of England Norfolk	James Paget University Hospital NHS …	1/1
23 Mar 2015	Robert Spring 2015-0123 · Paul Smith Inadequate communication channels failed to inform the Fire and Rescue Service about high-risk home oxygen users who smoked, preventing assessment for crucial …	East Midlands Lincolnshire (Central)	Air Liquide Lincolnshire County Council NHS Lincolnshire West Clinical Commissioning … United Lincolnshire Hospitals NHS Trust	1/4
23 Mar 2015	James Bateley 2015-0115 · Penelope Schofield Nursing homes and community nurses face significant delays in accessing essential wound dressings, as orders through GPs can take weeks, impacting patient …	South East West Sussex	NHS Coastal West Sussex Clinical … Sussex Community NHS Trust	2/2
23 Mar 2015	Barbara Mayer 2015-0113 · Jacqueline Lake Carer fatigue was not followed up, inconsistent crisis team contacts prevented establishing trust, and urgent help was delayed due to increased demand. …	East of England Norfolk	Norfolk and Suffolk NHS Foundation …	1/1
23 Mar 2015	Elliott Bignall 2015-0111 · Penelope Schofield The railway foot crossing was poorly lit with inadequate signage, posing a danger to pedestrians who might not see or hear approaching …	South East West Sussex	Network Rail	0/1
23 Mar 2015	Neil Budziszewski 2015-0109 · Peter Dorries Multiple failures in police custody included incomplete and unreviewed risk assessments, lack of 30-minute rousing checks for an alcoholic detainee, and inadequate …	Yorkshire and the Humber South Yorkshire (West)	South Yorkshire Police	1/1
23 Mar 2015	Pamela Pattison 2015-0108 · John Pollard Deficient nurse training on diabetes, doctors omitting critical insulin, and a lack of specialist support, consultant cover, and essential equipment were identified. …	North West Manchester (South)	Stockport NHS Foundation Trust	0/1
23 Mar 2015	Joseph Allison 2015-0103 · Ian Wade QC Service engineers lack specific training on a known stairlift defect and safety checks. Furthermore, no national safety recall or industry-wide advisory has …	London London (East)	British Healthcare Trades Association Handicare Accessibility Ltd	2/2
20 Mar 2015	Kingsley Burrell 2015-0472 · Louise Hunt There is a national lack of understanding and training regarding acute behavioural disturbance and the risks of prolonged restraint. Additionally, specialized mental …	West Midlands Birmingham and Solihull	National mental health working group Association of Ambulance Chief Executives Association of Chief Police Officers Department of Health and Social …	3/4
20 Mar 2015	Brenda Leyland 2015-0112 · Catherine Mason Helium gas canisters are freely available in large volumes without purchase controls or modified valves to restrict gas release, posing an uncontrolled …	East Midlands Leicester (City & South)	Department of Health and Social …	1/1