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 280 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
20 Feb 2015	Daniel Strickland 2015-0505 · Sarah Whitby Deficient information management included a lack of written handovers, inaccurate logs, an inaccessible daily log, and no clear method for sharing critical …	South East Southampton and the New Forest	St Edward’s School	0/1
20 Feb 2015	Maria Nekrasova 2015-0141 · Paul Matthews The bridge lacked essential pedestrian safety measures, including central barriers and adequate lighting. This created dangerous conditions where oncoming headlights blinded drivers …	London London (Inner South)	Department for Transport London Borough of Lambeth City of Westminster Transport for London	1/4
20 Feb 2015	Lexie Harrison 2015-0070 · Melanie Williamson A critical lack of national and local standardised policies for paediatric oesophageal varix banding procedures leads to inconsistent consultant practices. This impacts …	Yorkshire and the Humber West Yorkshire (East)	British Society of Paediatric Gastroenterology Leeds Teaching Hospitals NHS Trust NHS Improving Quality Sheffield Children’s NHS Foundation Trust	2/4
20 Feb 2015	Laura Hill 2015-0092 · Gareth Lewis There was a breakdown in information transfer between child and adult mental health teams, coupled with ward understaffing and critical training needs …	Wales Carmarthenshire & Pembrokeshire	Hywel Dda University Health Board	1/1
20 Feb 2015	Richard Jones 2015-0068 · Ian Singleton Inadequate recording of patient information, perceived risk levels, and assessment urgency was observed. There was also contradictory evidence and confusion regarding responsibilities …	South West Wiltshire & Swindon	Avon and Wiltshire NHS Mental … Department of Health and Social … Ministry of Defence Public Health England	5/6
20 Feb 2015	Michael Lyons 2015-0067 · Nadia Persaud The care agency failed to act on swallowing assessment recommendations, resulting in an inadequate care plan that did not specify choking prevention …	London London (East)	John Stanley Agency	1/1
19 Feb 2015	John Dack 2015-0151 · ME Hassell Critical administrative failures, specifically incorrect patient addresses in medical notes despite multiple notifications, led to missed follow-up appointments and have previously resulted …	London London Inner (North)	Barts Health	1/1
19 Feb 2015	Alexander Ball 2015-0069 · David Roberts Critical communication breakdowns between the Trust and other agencies, compounded by the absence of a dedicated Care Co-ordinator, resulted in inadequate care …	North West Cumbria	Cumbria Partnership NHS Foundation Trust	2/1
19 Feb 2015	Barrie Lewis 2015-0065 · Andrew Barkley The provided text is incomplete and does not contain any discernible coroner's concerns.	Wales Powys, Bridgend & Glamorgan Valleys	Cwm Taf Health Board	1/1
19 Feb 2015	Elizabeth Leah 2015-0064 · John Pollard Severe ambulance service understaffing and resource shortages led to dangerous delays, resulting in an elderly patient with a broken leg being advised …	North West Manchester (South)	Department of Health and Social …	1/1
19 Feb 2015	Maria Silkin 2015-0061 · John Pollard The care home's falls risk assessment contained inaccurate information regarding the patient's fall history. This misrepresentation led to a dangerous delay in …	North West Manchester (South)	Appleton Lodge Care Home	0/1
18 Feb 2015	Keri Holdsworth 2015-0060 · C W M Donnelly This junction is a recurring danger zone with a history of several serious and fatal incidents, specifically for vehicles making right turns …	North East Hartlepool	Hartlepool Borough Council Highways Agency	2/2
18 Feb 2015	Alan Jones 2015-0059 · Paul Bennett Inadequate GP training on electronic patient systems hindered access to critical clinical information. Software design failures also prevented important patient conditions from …	Wales Swansea & Neath Port Talbot	NHS England NHS Wales Royal College of General Practitioners Welsh Assembly Government	1/4
18 Feb 2015	Henry Powell 2015-0058 · Lydia Brown Discharge planning was inappropriate due to insufficient staff training on bed rails. There were also policy conflicts between hospital and community services, …	East Midlands Leicester (City & South)	Leicester Partnership Trust University Hospitals of Leicester	2/2
17 Feb 2015	Huseyin Erdogan 2015-0066 · John Taylor Key action plans developed following a death, with a November 2014 completion date, remained largely unimplemented by the time of the inquest, …	London London (North)	Barnet Enfield and Haringey Mental …	0/1
17 Feb 2015	George Marks 2015-0057 · Kate Thomas Agency staff demonstrated a fundamental lack of understanding regarding medication administration policies, prescription chart recording, patient nursing notes documentation, and correct handover …	South East Mid Kent & Medway	Mayday Health Care Plc	1/1
16 Feb 2015	Mohammed Yousaf 2015-0056 · Lisa Hashmi There are no national guidelines on how to interpret and/or classify antenatal CTG tracings, and there were concerns about the dissemination, application, …	North West Manchester (North)	Department of Health and Social … Pennine Acute Hospitals NHS Trust Royal College of Obstetricians and …	0/3
16 Feb 2015	Richard Westgate 2015-0050 · Sheriff Stanhope Payne Aircraft cabin air contains organo-phosphate compounds harming occupant health and impairing flight control. There is no real-time monitoring of these compounds or …	South West Dorset	British Airways Civil Aviation Authority	2/2
13 Feb 2015	Christopher Taylor 2015-0055 · Maria Voisin The dispatch team lacked immediate visibility of incoming incidents, hindering timely action. Also, the landowner of a high-risk river stretch should consider …	South West Avon	Avon and Salisbury Constabulary Bath and North East Somerset … Sainsburys Plc	2/3
13 Feb 2015	Francoise Snape 2015-0054 · Geraint Williams No VTE assessment was performed due to staff misconceptions and perceived busyness. Staff also lacked knowledge of NICE guidelines regarding DVT prevention …	West Midlands Worcestershire	Worcestershire Acute Hospitals NHS Trust	0/1