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 278 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
19 Mar 2015	Elsie Hayward 2015-0224 · Andrew Barkley Overstretched medical staff due to excessive patient ratios led to care deficiencies, including neglected neuro observations and poor note-taking. This resulted in …	Wales Cardiff & Vale of Glamorgan	Cardiff and Vale NHS Trust	1/1
19 Mar 2015	Valerie Walton 2015-0107 · S McGovern The positioning of a pedestrian crossing on the apex of a sharp bend was a factor in the death, and the coroner …	West Midlands Coventry	Coventry City Council	1/1
19 Mar 2015	Anne Fowler 2015-0104 · Andrew Thompson Smoke alarm covers were left in place after installation, making them inaccessible and ineffective. Legislation should require their removal by builders or …	West Midlands Black Country	Home Office	0/1
18 Mar 2015	Anais Thouvenot 2015-0110 · Christina Swann The road junction at Upper Kings Street and Regent Road has significant safety concerns due to poor visibility, inadequate filter lanes, heavy …	East Midlands Leicester (City & South)	Leicester Campaign Cycling Group Leicester City Council	1/2
18 Mar 2015	Grant Benson and Gordon Davidson 2015-0102 · Andrew Tweddle Ambulance control failed to accurately locate a severe incident due to inaccurate GPS and a call handler's lack of local knowledge. Inadequate …	North East County Durham & Darlington	Yorkshire Ambulance Service	2/1
17 Mar 2015	Alasdair Penny 2015-0106 · Michael Burgess Bridge railings are easily mounted, facilitating suicides. Despite existing support notices, physical barriers should be reconsidered to prevent spontaneous jumps from the …	South East West Sussex	Sussex Police West Sussex County Council	2/2
17 Mar 2015	Kevin Hoey 2015-0101 · William Morris The East of England Ambulance Service needs to review training from another trust to improve paramedic decisions on whether to treat patients …	East of England Cambridgeshire (North & East)	East of England Ambulance Service …	1/1
16 Mar 2015	Tom Sawyer and Danny Winters 2015-0100 · David Ridley Reliance on insecure handwritten radio logs, absence of critical communication records, and ineffective communication between soldiers hindered investigation. There is a lack …	South West Wiltshire & Swindon	Minister of State for the …	1/1
16 Mar 2015	Joshua Booth 2015-0125 · Stuart Fisher A seriously substandard, subsided road section poses an immediate danger to motorists, requiring urgent repair, warning signage, and an advisory speed limit. …	East Midlands Lincolnshire (Central)	Lincolnshire County Council	1/1
13 Mar 2015	Philip Robinson 2015-0225 · Elizabeth Didcock Unclear ECG guidelines for breathlessness, unsatisfactory safe discharge audits, and inadequate communication of Early Warning Scores (EWS) are significant concerns. Delays in …	East Midlands Nottinghamshire	Doncaster and Bassetlaw Hospitals NHS …	1/1
13 Mar 2015	James McManus 2015-0097 · Lisa Hashmi Trust staff demonstrated a lack of knowledge and failure to implement key protocols for managing bleeding related to thrombolytic therapy and massive …	North West Manchester (North)	Pennine Acute Hospitals NHS Trust	1/1
13 Mar 2015	Maurice Cowling 2015-0096 · Paul Kelly Despite the rarity of deaths from certain medical procedures, three fatalities occurred within a short period, two within the Trust, indicating a …	Yorkshire and the Humber North Lincolnshire & Grimsby	North Lincolnshire and Goole Hospitals …	1/1
12 Mar 2015	Ronald Gittens 2015-0117 · Andrew Walker Issues identified include the transfer of acute psychiatric patients when no bed is available and the use of Crisis Resolution Home Treatment …	London London (North)	Barnet Enfield and Haringey Mental … Department of Health	1/2
12 Mar 2015	Robbie Williamson 2015-0105 · Richard Taylor Concerns exist regarding exposed, raised pipework, potentially attached to bridges, that is accessible to the public and may pose a safety risk.	North West Lancashire (East)	Association of Independent Gas Transporters Northern Gas Network Scotia Gas Network Wales and West Utilities	0/4
12 Mar 2015	Nicola Tweedy 2015-0095 · Jacqueline Lake Critical safety procedures were missed, including failure to provide specific aftercare information and incomplete Thromboprophylaxis Risk Assessments, which should have flagged patient …	East of England Norfolk	Norfolk and Norwich University Hospital …	2/1
12 Mar 2015	Elizabeth Cox 2015-0094 · Heidi Connor Concerns were raised about proposed reductions in night-time ward staffing, which risks staff having insufficient capacity to safely care for patients due …	East Midlands Nottinghamshire	Sherwood Hospitals NHS Foundation Trust	1/1
11 Mar 2015	Leah Levine 2015-0093 · John Pollard Lack of clearly written conditions for temporary hospital leave, including supervision levels and observation regimes, led to conflicting staff understanding and poor …	North West Manchester (South)	Greater Manchester West Mental Health …	1/1
11 Mar 2015	Neil Westerman 2015-0091 · John Pollard Pre-operative assessments by junior doctors instead of the consultant led to missed vital information. Operation notes lacked equipment details, and there were …	North West Manchester (South)	Stockport NHS Foundation Trust	1/1
11 Mar 2015	Bradley Griffiths 2015-0090 · Catherine Mason Health visitor services failed to maintain contact and track a child after the mother moved without providing new GP or address details, …	East Midlands Leicester (City & South)	Integrated Children's Services, Coventry Coventry and Warwickshire NHS Trust	1/2
9 Mar 2015	Darren Linfoot 2015-0089 · Peter Bedford Non-controlled opiate drugs lacked audit, risking them going unaccounted for. Inconsistent methods for patient observations and radio nurse duties indicated a need …	South East Berkshire	West London Mental Health NHS …	0/1