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 279 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
9 Mar 2015	Leonardus Vries 2015-0088 · Geraint Williams Significant documentary failings and lack of audit for non-controlled medication created opportunities for abuse or theft, highlighting a need for improved internal …	West Midlands Worcestershire	Royal Orthopaedic Hospital NHS Foundation …	1/1
9 Mar 2015	Craig Bell 2015-0087 · Nigel Meadows There was an unmet need for psychological therapies for prisoners with personality disorders, poor information sharing about self-harm risk, and a lack …	North West Manchester City	MHSC HMP Manchester MHSC Ministry of Justice	0/5
9 Mar 2015	Andrew Peacock 2015-0086 · Andrew Tweddle The absence of regulations requiring amber warning beacons on tractors on all roads, not just dual carriageways, may reduce visibility and increase …	North East County Durham & Darlington	Department for Transport	1/1
6 Mar 2015	Mary Marshall 2015-0084 · Alan Walsh A general lack of awareness among hospital staff and GPs about the importance of GDH positive results, which indicate Clostridium Difficile vulnerability, …	North West Manchester (West)	Department of Health and Social …	1/1
6 Mar 2015	Emmeline Hampson 2015-0083 · Alan Walsh Inadequate review of falls risk assessments after repeated falls and patient condition changes was noted. Poor documentation, an insufficient alarm system, and …	North West Manchester (West)	Pindy Enterprises Limited	0/1
6 Mar 2015	Connor Turner 2015-0082 · David Hinchliff There was no system for training or supervising parents/carers in oxygen supply transfer, nor an independent check of apparatus function and user …	Yorkshire and the Humber West Yorkshire (East)	Leeds Teaching Hospitals NHS Trust	1/1
6 Mar 2015	Thor Dalhaug 2015-0063 · Stuart Fisher Failures included unsupervised surgeons, inappropriate techniques, incomplete medical records, and a lack of candour in disclosing circumstances surrounding a neonatal death, hindering …	East Midlands Lincolnshire (Central)	United Lincolnshire Hospitals NHS Trust	1/1
5 Mar 2015	Archie Hexall 2015-0081 · Philip Barlow A communication breakdown between midwives led to critical information about a newborn's respiratory distress being lost, with temporary notes not retained and …	London London (Inner South)	Lewisham and Greenwich NHS Trust	1/1
4 Mar 2015	Brian Francis 2015-0085 · Sarah-Jane Richards A flawed consultant attendance logging system meant a patient was not reviewed. Lack of access to community medical records at admission delayed …	Wales Powys, Bridgend & Glamorgan Valleys	Abertawe Bro Morgannwg University Health … National Assembly for Wales	1/2
4 Mar 2015	Colin Tyson 2015-0080 · Nicola Mundy Concerns were raised about GPs' interpretation of patient confidentiality, which may prevent family members from sharing vital information about vulnerable individuals at …	Yorkshire and the Humber South Yorkshire (East)	NHS England	1/1
4 Mar 2015	David Bladen 2015-0079 · Nicola Mundy There is an absence of clear guidance for optimal thromboprophylaxis management in patients with restricted mobility due to braces, but not in …	Yorkshire and the Humber South Yorkshire (East)	National Institute for Health and …	1/1
5 Mar 2015	Michael Pollard 2015-0078 · Lydia Brown An outdated hospital switchboard rota led to critical delays in contacting the correct on-call consultant for an emergency, highlighting a need for …	East Midlands Leicester (City & South)	University Hospitals of Leicester NHS …	1/1
4 Mar 2015	Kimberley Parsons 2015-0077 · P Harrowing Unjustified advice on 'assisted self-harming' was given without research backing, consultant approval, or documentation, indicating a lack of clear protocols for novel …	South West Avon	Avon and Wiltshire Mental Health … Care Quality Commission	2/2
3 Mar 2015	Thomas Taylor 2015-0076 · Andrew Tweddle The falls risk assessment policy fails to presume increased risk for certain patient classes, like stroke patients, potentially leading to misclassification and …	North East County Durham	County Durham and Darlington NHS …	0/1
3 Mar 2015	Paige Bell 2015-0075 · Derek Winter Fragmented patient records, a lack of electronic access to all notes, and inconsistent engagement policies across trusts compromise patient care. Outdated guidance …	North East Sunderland	Department of Health and Social …	2/1
2 Mar 2015	Alison Evers 2015-0074 · Jan Alam The care facility lacked a written 'no treats policy' and a policy for ensuring a first-aid-trained staff member on every shift. Furthermore, …	Yorkshire and the Humber West Yorkshire (East)	Leeds City Council	1/1
2 Mar 2015	Peter Wright 2015-0073 · Andrew Haigh Severe hospital understaffing led to a single qualified nurse managing 16 patients, resulting in missed observations and policy-breaching drug rounds. Additionally, the …	West Midlands Staffordshire (South)	South Staffordshire and Shropshire NHS …	1/1
27 Feb 2015	Malcolm Burge 2015-0072 · Michael Rose Council debt recovery procedures failed to accommodate a vulnerable individual's age, mental awareness, and inability to use modern communication methods, contributing significantly …	South West Somerset (West)	Newham Council	0/1
26 Feb 2015	Simon Costin 2015-0071 · Catherine Mason Inconsistent patient assessment approaches by clinicians and a lack of nationally agreed standard assessment forms hinder effective communication and care continuity for …	East Midlands Leicester (City & South)	NHS England	1/1
24 Feb 2015	Christopher Butler 2015-0482 · Peter Clark A hidden electrical fault in boiler systems, potentially present in other similar properties, poses an undetected risk that standard electrical testing may …	South East Oxfordshire	Fire and Rescue Oxfordshire	1/1