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 284 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
19 Dec 2014	Thomas Jenkins 2014-0543 · Sarah-Jane Richards Slow Tissue Viability Nurse response and inadequate wound care input, exacerbated by specialist nurses not being hospital-based and an overstretched regional TVN …	Wales Powys, Bridgend & Glamorgan Valleys	Cwm Taf University health Board, …	0/1
19 Dec 2014	Samia Shara 2014-0548 · Fiona Willcox There was a lack of audit for complex 999/111 calls to identify learning opportunities, and call takers could inappropriately downgrade calls, potentially …	London London Inner (West)	NHS England North West Collaborative Clinical Commissioning …	0/2
19 Dec 2014	Pauline Edwards 2014-0547 · Fiona Wilcox UK hospitals allowed EU-trained doctors to practice unsupervised without ensuring equivalent training or experience, driven by EU law, thereby increasing patient risk.	London London Inner (West)	Department of Health and Social …	1/1
18 Dec 2014	William Savage Darren Salter Intelligence regarding frequent "PISTOL hits" was inaccurately circulated, leading commanders to believe a route was cleared when it was not. More detailed …	South East Oxfordshire	Ministry of Defence	1/1
18 Dec 2014	Kevin Lawrenson 2014-0577 · Darren Salter Numerous accidents occurred due to inadequate and poorly visible signage for slow-moving vehicles. Improvements such as larger signs, lane separation, or electronic …	South East Oxfordshire	Highways Agency	1/1
18 Dec 2014	Brendan Ryan 2014-0541 · Andrew Barkley The provided text only describes the vehicle leaving the road and colliding with a fence, resulting in death, without detailing specific preventative …	Wales Powys, Bridgend & Glamorgan Valleys	Powys County Council	1/1
18 Dec 2014	John Stabler 2014-0552 · Stuart Fisher The Prisoner Escort Record requires review and redesign. Furthermore, medical records systems need to be consistently available in reception and care areas …	East Midlands Central Lincolnshire	HMP Lincoln HMP North Sea Camp National Offender Management Service NHS England	0/5
18 Dec 2014	Robert Stuart and Darren Hughes 2014-0549 · Christopher Woolley NHSBT could improve the core donor data form with more information and ensure all relevant information is transmitted to transplant centres; UHW …	Wales Cardiff & the Vale of Glamorgan	NHS Blood and Transplant University Hospital of Wales	1/2
17 Dec 2014	Connor Smith 2014-0540 · Andre Rebello An error in a PPO investigation listed an officer as attending a segregation review when they were absent, indicating poor investigation quality …	North West Liverpool	Ministry of Justice National Offender Management Service Prison and Probation Ombudsman	2/3
17 Dec 2014	Darren Hayes 2014-0538 · Jacqueline Lake Patient contact attempts were not documented or escalated, resulting in a five-week delay to follow up a high-risk individual. Key external health …	East of England Norfolk	Norfolk County Council	1/1
17 Dec 2014	Rebecca Overy 2014-0535 · Stephanie Haskey An immediate transfer, mandated by law, was detrimental to a young adult's mental health. This highlighted a critical service gap for secure …	East Midlands Nottinghamshire	Department of Health and Social …	0/1
16 Dec 2014	John Leyin 2014-0563 · Caroline Beasley-Murray There was a failure to disseminate trust policy and NPSA guidance, along with weak training systems. Staff training currency was not checked, …	East of England Essex	Basildon Hospital NHS Trust	1/1
16 Dec 2014	Mikey Hornby 2014-0536 · John Pollard The out-of-hours service repeatedly failed to appreciate the seriousness of an infant's condition, delaying hospital admission and critical antibiotic treatment. The GP …	North West Manchester (South)	Bridgewater Community Healthcare NHS Trust	1/1
15 Dec 2014	Andrew Aitken 2014-0561 · ME Hassell Inadequate management of patient's belongings and medication on admission, failure to seek crucial past psychiatric history, and poor discharge planning for a …	London London Inner (North)	Barts NHS Trust East London NHS Trust	2/2
15 Dec 2014	Rhys Williams 2014-0558 · John Pollard There appeared to be a lack of training of carers, uncertainty regarding rules for positioning 'profile beds', and concerns about the assessment …	North West Manchester (South)	Ayslebury Partnership King's College Hospital NHS Foundation … London Borough of Southwark (Housing … Sunrise Senior Living	1/4
16 Dec 2014	Janette Insley 2014-0574 · Lisa Hashmi Inpatients lacked access to psychological treatment due to unavailable psychologists and resources, with an overemphasis on community services, leaving vulnerable patients without …	North West Manchester (North)	Department of Health and Social …	1/1
12 Dec 2014	Simon Satchwell 2014-0537 · Edward Thomas Concerns relate to the lack of clear, consistent international regulations for minors operating jet skis, particularly regarding age restrictions and required adult …	East of England Hertfordshire	Foreign, Commonwealth & Development Office	0/1
12 Dec 2014	Jason Palmer 2014-0534 · John Tomlin A breakdown in information sharing between police units meant domestic incident details were not available to the Firearms Unit, impacting suitability assessment …	South West Exeter and Greater Devon	Devon and Cornwall Constabulary	1/1
10 Dec 2014	Patricia Edge 2014-0531 · Simon Allen An excessive paracetamol dose was prescribed and dispensed due to inadequate staff training and procedures, compounded by a failure to review the …	North West Manchester (West)	Mark Reynolds Solicitors Royal Bolton Hospital NHS Foundation …	1/2
10 Dec 2014	Geraldine Kilborn 2014-0532 · Andrew Tweddle There was a clear breakdown in mental health information sharing within ACCT reviews, where mental health input was not sufficiently weighted and …	North East County Durham & Darlington	Care UK National Offender Management Service Tees Esk Wear Valley NHS …	3/3