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 283 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
15 Jan 2015	Judith Saville 2015-0011 · Andrew Cox Over-prescription of medication to a patient with a history of overdoses was identified. There was a lack of a robust computer system …	South West Exeter & Greater Devon	Axminster Medical Practice Devon Partnership NHS Trust	2/2
14 Jan 2015	Max Carlton-Smith 2015-0007 · Andrew Harris Organizers of an unlicensed rave failed to provide medical assistance, delayed calling emergency services, and operated in an unsafe venue with poor …	London London (Inner South)	Department of Health and Social …	1/1
9 Jan 2015	Annette Charlton 2015-0009 · Louise Hunt Pharmaceutical manufacturers are producing medications in almost identical packaging, which significantly increases the risk of dispensing errors and poses a serious threat …	West Midlands Birmingham & Solihull	Crescent Pharma Ltd Department of Health and Social … General Pharmaceutical Council Medicines and Healthcare products Regulatory …	1/6
9 Jan 2015	Pauline Taylor 2015-0008 · Kevin McLoughin Ambiguity in the surgical term "nephroureterectomy" caused critical misunderstandings between clinicians regarding procedure extent. There was also an absence of a case …	Yorkshire and the Humber West Yorkshire (East)	Department of Health and Social … Leeds Teaching Hospitals NHS Trust	2/2
9 Jan 2015	Jason Lawson 2015-0006 · Robert Chapman Welfare checks failed to identify a deceased prisoner. Prison healthcare lacked a computer-driven system to track missed and lapsed prescriptions, and there …	East Midlands Rutland & North Leicestershire	HM Prison and Probation Service NHS England	0/2
9 Jan 2015	Mark Burdett 2015-0005 · S McGovern A lack of signage warning motorists about a concealed entrance posed a significant safety risk, especially for traffic approaching from a particular …	West Midlands Warwickshire	Warwickshire City Council	0/1
9 Jan 2015	Thomas Hunt 2015-0004 · ARW Forrest A number of unrecorded non-injury collisions indicate a hazardous road section. The existing 60mph speed limit on a village road bordered by …	East Midlands South Lincolnshire	North LCC Highways North Lincolnshire Council	1/2
8 Jan 2015	George Hulme 2015-0016 · Christopher Murray Care home agency staff lacked resident identification information and adequate induction. Rooms were not clearly marked, leading to confusion during emergencies and …	North West Manchester (South)	Bamford Grange Nursing Home	0/1
8 Jan 2015	Eve Cullen 2015-0002 · G U Williams Referrals from hospital were not actioned or treated as urgent due to a lack of service-wide definition for "urgent" and no agreed …	West Midlands Worcestershire	Worcestershire Health and Care NHS …	1/1
6 Jan 2015	John Ioannou 2015-0012 · Andrew Walker There is a lack of clear guidance for General Practitioners when patients fail to collect essential mental health medication, potentially compromising treatment …	London London (North)	Department of Health and Social …	1/1
6 Jan 2015	Dale Proverbs 2015-0010 · Andrew Walker Observation policies for secluded mental health patients were found to be inadequate under the current Code of Practice, which could lead to …	London London (North)	Department of Health and Social …	1/1
6 Jan 2015	Carla London 2015-0003 · Andrew Walker Concerns were raised about the need to consider NICE guidance on late-onset sepsis in premature babies and to research infection monitoring systems …	London London (North)	Department of Health and Social …	1/1
6 Jan 2015	Dean Elie 2015-0001 · Andrew Walker The report highlights a need for consideration of further legislation to address a critical point, indicating a gap in existing legal frameworks …	London London (North)	Department of Health and Social …	1/1
5 Jan 2015	James Fyfe 2015-0099 · Peter Bedford The cot side on a trolley could remain in an unlocked position due to design and maintenance issues, which were not clearly …	South East Berkshire	Anetic Aid Limited Medicines and Healthcare Products Regulatory … Royal Berkshire Hospital Trust	3/3
28 Dec 2014	Alex Kelly 2014-0555 · Patricia Harding A vulnerable child was sentenced without forensic psychiatric assessment, and mental health support conflicted with disciplinary procedures, failing to adopt a holistic …	South East Mid Kent & Medway	HMP Cookham Wood Medway Youth Offending Team Ministry of Justice Oxleas NHS Foundation Trust	5/5
24 Dec 2014	David Mountain 2014-0554 · Jacqueline Lake Post-pacemaker insertion, chest pain and bleeding risks were not fully investigated for days, with a critical echocardiogram delayed and its results unavailable …	East of England Norfolk	Queen Elizabeth Hospital	1/1
23 Dec 2014	Alois Piska 2014-0553 · David Horsley The care home suffered from inadequate staffing levels, leading to insufficient supervision of residents in communal areas.	South East Portsmouth & South East Hampshire	Care UK Harry Sotnick House Portsmouth City Council	1/3
22 Dec 2014	Noreen Porter 2014-0550 · Louise Hunt Care home staff failed to perform CPR, indicating a complete absence of processes or procedures for emergency resuscitation.	West Midlands Birmingham & Solihull	BUPA Ardenlea Grove Nursing Home	1/1
22 Dec 2014	Percy Gurton 2014-0546 · Caroline Beasley-Murray The bus design was flawed, lacking a necessary safety barrier in front of the front passenger seat.	East of England Essex	First Essex Buses	1/1
22 Dec 2014	Edwin Thompson 2014-0542 · Terence Carney A clear, concise directive is needed for care home staff to promptly seek medical advice for residents experiencing pain, especially if it …	North East Gateshead & South Tyneside	Quality Care Commission South Tyneside Council	0/2