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 282 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
30 Jan 2015	Simon Tree 2015-0032 · Simon Wickens The unit's new airlock system has security flaws, allowing patients to 'tailgate' visitors and leave, with inadequate monitoring by reception staff.	South East Surrey	Surrey and Borders Partnership NHS …	1/1
30 Jan 2015	Michael McCrory 2015-0030 · Andre Rebello The therapeutic observation policy was not consistently followed, with staff recording 'on ward' instead of precise patient whereabouts, and there was unclear …	North West Liverpool	Cheshire and Wirral Partnership NHS …	0/1
30 Jan 2015	Isaac Nash 2015-0028 · Dewi Pritchard Strong and unpredictable currents in Aberffraw beach's river estuary pose a danger, as visitors lack local knowledge and there are no warning …	Wales North West Wales	Ynys Mon County Council	1/1
29 Jan 2015	John Matthews 2015-0034 · John Pollard Emergency department care was compromised by a nurse triaging without the PRF, a locum doctor's inability to access patient records, omitted neurological …	North West Manchester (South)	Stockport NHS Foundation Trust	1/1
29 Jan 2015	Margaret Flemming 2015-0029 · Thomas Osborne There was an unacceptable three-month delay in conducting a Best Interests Assessment for a Deprivation of Liberty Safeguarding Authorisation, leaving a vulnerable …	East of England Bedfordshire & Luton	Central Bedfordshire Council	1/1
29 Jan 2015	Phyllis Barlow 2015-0027 · Christopher Woolley Widespread ignorance among GP practices of NICE guidelines means patients on warfarin with head injuries are not being admitted to hospital for …	Wales Cardiff & Vale of Glamorgan	NHS Wales	1/1
29 Jan 2015	Brian Marks 2015-0025 · John Pollard PEJ and PEG tubes are easily confused due to their similar appearance, highlighting the lack of a simple colour-coding system for differentiation.	North West Manchester (South)	Department of Health and Social …	1/1
28 Jan 2015	Katherine Bonaventura 2015-0031 · Alison Hewitt The system for assessing detained patients returning from leave is flawed, lacking thorough family/carer consultation and adequate mental state assessment documentation.	South East Surrey	Surrey and Borders Partnership NHS …	0/1
28 Jan 2015	Lana-Liza Chervonenko 2015-0022 · Nadia Persaud High activity on the labour ward led to delayed medical reviews, incorrect emergency grading, incomplete patient assessments, and a flawed prioritisation decision, …	London London (East)	Queen’s Hospital	0/1
27 Jan 2015	Susanna Geraty 2015-0026 · Karen Henderson Post-operative care failures included inadequate fluid balance monitoring and recording, poor nursing records, failure to recognise an acutely unwell patient, and unaddressed …	South East Surrey	East Surrey Hospital	1/1
27 Jan 2015	Rafel Delezuch 2015-0024 · Martin Gotheridge Emergency department staff lacked awareness and training on restraint policies, the dangers of prone restraint, and suitable medications for rapid tranquilisation, leading …	East Midlands Leicester City & South Leicestershire	Leicester University Hospitals NHS Trust	1/1
23 Jan 2015	Hilary Moock and Janice Taylor 2015-0020 · Penelope Schofield An ancient, high-risk rural road with poor design, unlit conditions, and a difficult, low-visibility entrance creates a dangerous situation for turning vehicles.	South East West Sussex	West Sussex County Council	1/1
20 Jan 2015	James Colton 2015-0021 · Geraint Williams Prison healthcare staff failed to correctly diagnose and treat Mr Colton, missing his developing cancer due to not revisiting the initial diagnosis. …	West Midlands Worcestershire	HMP Long Lartin Healthcare Worcestershire Health and Care Trust	1/2
21 Jan 2015	Sian Armstrong 2015-0019 · Maria Voisin A significant delay occurred in providing Cognitive Behavioural Therapy (CBT) for a child, Sian Armstrong, who was assessed as needing it, highlighting …	South West Avon	North Bristol NHS Trust	0/1
21 Jan 2015	Robert Jones 2015-0018 · Elizabeth Earland Communication failures meant staff were unaware of a patient's total falls, an outdated post-falls checklist was used, and neurological observations were not …	South West Exeter & Greater Devon	North Devon Healthcare NHS Trust South Molton Community Hospital South Molton Health Care Centre	2/3
21 Jan 2015	Philip Smith 2015-0017 · Mary Burke Extensive failures in nursing and doctors' record-keeping, including missed observations and medications. A junior doctor also declined a senior medical review despite …	Yorkshire and the Humber West Yorkshire (West)	Huddersfield Royal Infirmary	0/1
20 Jan 2015	Awa Jeng 2015-0015 · Nadia Persaud A high-risk patient for renal failure was not closely monitored, and critical blood tests and checks directed by a consultant were not …	London London (East)	Barts Health	1/1
19 Jan 2015	Simon Alliston 2015-0023 · Thomas Osborne A patient with a long mental health history was discharged without a formal handover or recorded reason, despite the community team believing …	East of England Bedfordshire & Luton	South Essex Partnership University NHS …	1/1
16 Jan 2015	Robert Anstice 2015-0014 · Jacqueline Lake Critical recommendations for support and care coordination were not actioned, and communication breakdowns meant team members were unaware of appointments. The patient …	East of England Norfolk	Norfolk and Suffolk NHS Foundation …	0/1
16 Jan 2015	Louise Henry 2015-0013 · Sophie Cartwright A critical misunderstanding existed between mental health teams regarding care coordination and adherence to the Care Programme Approach (CPA), leading to confusion …	East Midlands Derby & Derbyshire	Derbyshire County Council Derbyshire Healthcare NHS Foundation Trust NHS England	2/3