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 281 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
13 Feb 2015	Robert Yarnell 2015-0052 · Rachael Griffin After the patient's discharge from a mental health unit, the Burnley and Pendle Complex Care and Treatment Team did not make sufficient …	North West Manchester (West)	Lancashire Care NHS Foundation Trust	0/1
12 Feb 2015	Andrew Frost 2015-0119 · ME Hassell A crucial misunderstanding existed between the GP and the crisis team regarding the team's capacity for emergency assessment, highlighting a need for …	London London North (Inner)	Killick Street Health Centre	1/1
12 Feb 2015	Isobel Griffin and Jane Clark 2015-0049 · Belinda Cheney For Jane Clark, challenging events were not handed over, the nurse in charge did not read the notes before granting leave, risk …	East Midlands Northamptonshire	Northamptonshire NHS Partnership Trust and …	0/1
12 Feb 2015	X Rokeby 2015-0048 · Anne Pember Despite an action plan stating training was offered to transport services regarding spontaneous haemorrhage, a volunteer driver involved in the incident confirmed …	East Midlands Northampton	NSL Care Services	0/1
11 Feb 2015	Rufjan Bibi 2015-0053 · ME Hassell Inadequate nursing care for an incontinent patient, a nurse's suggestion of private care, and an unexplained five-hour delay for consultant review despite …	London London Inner (North)	Barts Health	1/1
11 Feb 2015	Anne Horner 2015-0047 · Simon Nelson The design of an outward-opening toilet cubicle door led to two identical head injuries within six weeks, indicating a systemic risk, especially …	North West Manchester (North)	Bury Metropolitan Borough Council Care Quality Commission Department of Health and Social … Messrs. Latimer Lee Solicitors	1/5
10 Feb 2015	Jane Robinson 2015-0051 · Catherine Mason Basic observations were repeatedly not recorded, with no senior review or written rationale for observation frequency. A lack of reporting and support …	East Midlands Leicester (City & South)	University Hospitals Leicester	1/1
9 Feb 2015	Margaret Clarke 2015-0046 · Nicola Mundy There is a lack of guidance for the effective cleaning of fixed shower heads, which are increasingly common in private and public …	Yorkshire and the Humber South Yorkshire (East)	Doncaster Borough Council Health and Safety Executive	2/2
2 Feb 2015	George Taylor 2015-0044 · Andrew Cox A significant number of patients are being sent out of county monthly due to an ongoing lack of acute psychiatric beds, posing …	South West Cornwall	Department of Health and Social … Kernow Clinical Commissioning Group	2/2
6 Feb 2015	Jordan Roberts 2015-0042 · Andrew Tweddle Inadequate and poorly located warning signs failed to highlight the dangers of a particularly deep pool with strong currents in the River …	North East County Durham & Darlington	Durham County Council Finchale Abbey Farm	1/2
5 Feb 2015	Stanley Ward 2015-0045 · Zafar Siddique Care staff lacked awareness of increased bleeding risks for warfarin patients after falls. The facility also lacked clear policies or training for …	West Midlands Black Country	Care Quality Commission Lapal House and Lodge Care …	0/2
4 Feb 2015	Paul Moroney 2015-0043 · John Pollard Oxygen saturations were neither monitored nor recorded during the initial hospital visit and subsequent discharge, leading to a lack of crucial information …	North West Manchester (South)	Tameside Hospital Foundation NHS Trust	1/1
4 Feb 2015	Paul Hardy 2015-0041 · Stephanie Haskey Healthcare staff failed to follow instructions for obtaining blood/urine samples for cancer investigation, neglected recommendations for INR monitoring, and did not conduct …	East Midlands Nottinghamshire	Nottinghamshire Healthcare NHS Trust	0/1
3 Feb 2015	Alexander Holt 2015-0040 · Christopher Dorries Failures included not challenging minimised suicidal intent, providing intended treatment, ensuring continuity of care, and maintaining information flow, leading to inadequate risk …	Yorkshire and the Humber South Yorkshire (West)	Sheffield Health and Social Care …	0/1
3 Feb 2015	Shannon Gee 2015-0039 · Andrew Cox Delays in mental health treatment occurred due to unaddressed gaps between organisational treatment thresholds and difficulties transferring medical notes, raising concerns about …	South West Cornwall	Department of Health and Social … Kernow Clinical Commissioning Group	0/2
3 Feb 2015	John Darling 2015-0037 · John Matthews An unguarded platform edge at a cafe, coupled with a slight incline, presents a serious fall hazard for patrons, particularly vulnerable individuals, …	South East Isle of Wight	Isle of Wight Council Off the Rails Cafe Owner of the "Off The …	0/3
2 Feb 2015	Tanya Page 2015-0038 · ME Hassell Critical information about a patient's self-harm attempt was not shared between hospital wards due to staff reluctance driven by fear of perceived …	London London Inner (North)	Camden & Islington NHS Foundation …	0/1
2 Feb 2015	Kimberley Lindfield 2015-0036 · Nigel Meadows Deficiencies include a lack of audit for mental health assessment referrals, absence of clear protocols for patient observation and clinical review changes, …	North West Manchester (City)	Clinical Commissioning Group for South … Department of Health and Social … Greater Manchester West Mental Health … Manchester Mental Health and Social …	2/6
2 Feb 2015	Darren Wright 2015-0035 · Jacqueline Lake Emergency response was hindered by a staff nurse's inability to locate the incident and a lack of recent CPR training among prison …	East of England Norfolk	HMP Norwich Serco Virgin Care Limited	3/3
2 Feb 2015	Martha Seaward 2015-0033 · Jacqueline Lake An acknowledged dangerous bus stop on a busy road has seen no action taken on long-standing concerns and feasibility studies for safety …	East of England Norfolk	Norfolk County Council	1/1