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.

Response tracker Organisations Advanced search

Keyword

Browse by year

Browse by region

Sort

Reports

6,383 reports · Page 285 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
10 Dec 2014	Garry Gilbey 2014-0533 · Karen Harrold The prison lacked a clear policy for calling ambulances or defining medical emergencies, leading to inadequate staff training for night-time assessments and …	South East Portsmouth & South East Hampshire	Department of Health and Social … Ministry of Justice	2/2
5 Dec 2014	Peter Mackie 2014-0528 · Richard Hulett Inadequate numbers of first aiders and healthcare staff were available across prison sites, compounded by a lack of clear guidance for staff …	South East Buckinghamshire	Springhill Prison	1/1
5 Dec 2014	Elaine Giles 2014-0529 · ARW Forrest An inaccurate pre-discharge assessment of a patient's functional ability, particularly with stairs, highlighted the need for more detailed home environment assessment and …	East Midlands South Lincolnshire	Peterborough and Stamford NHS Trust	0/1
5 Dec 2014	Jade Anderson 2014-0530 · Alan Walsh Concerns relate to inadequate dog management practices in a confined living space and fragmented, ineffective legislation on dog control that focuses on …		Department for Environment Food and …	1/1
5 Dec 2014	Paul Hyde 2014-0527 · Veronica Hamilton-Deeley Concerns arose regarding the effectiveness and timeliness of the mental health referral pathway for a patient with a deteriorating condition, despite anxieties …	South East Brighton & Hove	Brighton and Hove City Council Community Governance Sussex Partnership Trust	1/3
4 Dec 2014	Joanne Nobbs 2014-0560 · Jacqueline Lake A correlation between the deceased's deteriorating physical and mental health was noted but not investigated, and a care plan was not revised …	East of England Norfolk	Norfolk and Suffolk NHS Foundation …	1/1
4 Dec 2014	James Stewart 2014-0526 · Thomas Osborne There was no system for new GP practices to verify medication with previous providers for nursing home patients, leading to prescribing errors …	East of England Bedfordshire & Luton	Bedfordshire Clinical Commissioning Group	1/1
3 Dec 2014	Sandra Danks 2014-0525 · Clare Bailey An electricity supply interruption to the main oxygen apparatus stopped oxygen provision, as there was no backup system in place to continue …	North East Teesside	British Oxygen Philips Respironics	1/2
2 Dec 2014	Moses McDonald 2014-0524 · Lorna Tagliavini The Clozapine clinic failed to conduct mandatory and regular glucose testing for patients receiving antipsychotic medication, posing a significant safety concern.	London London (Inner South)	Russell-Cooke solicitors South London and Maudsley NHS …	1/2
2 Dec 2014	Anthony Williams 2014-0523 · John Gittins Staff lacked clear guidance on psychiatric assessment pathways for 'exceptional cases', medical records were inaccessible out-of-hours, and there was insufficient engagement with …	Wales North Wales (East & Central)	Betsi Cadwaladr University Health Board	1/1
27 Nov 2014	Freda Owens 2014-0559 · Alan Wilson There was a significant breakdown in information gathering and exchange between medical professionals, leading to incorrect assumptions about patient injuries, delayed specialist …	North West Blackpool & Fylde	Blackpool Teaching Hospital NHS Foundation … Croft House Rest Home Lancashire Teaching Hospitals NHS Foundation …	0/3
27 Nov 2014	David Greenfield 2014-0518 · Andrew Tweddle Staff lacked expertise in managing co-occurring drug and alcohol problems, internal reviews overlooked external research, and admission procedures for alcohol detox patients …	North East County Durham & Darlington	Priory Group Ltd	1/1
27 Nov 2014	Stephen Morris 2014-0522 · Alan Wilson Inadequate information exchange between mental health services when a patient moved areas led to a lack of detailed, up-to-date patient history, compromising …	North West Blackpool & Fylde	Cheshire and Wirral Partnership NHS … Lancashire Care NHS Foundation Trust	1/2
26 Nov 2014	Amanda Hawkins 2014-0516 · Margaret Jones Patient vulnerability was exacerbated by service changes and failures in coordinating care, including sending critical appointment letters directly to a patient unable …	West Midlands Staffordshire (South)	Walsall and Dudley Mental Health … West Midlands Police	1/2
26 Nov 2014	Anthony Huggan 2014-0517 · Lisa Hashmi The lack of a suitable out-of-hours service for drug addiction placed an undue burden on emergency services, with insufficient timely follow-up for …	North West Manchester (North)	Bury Metropolitan Borough Council	1/1
26 Nov 2014	Marjorie Ellery 2014-0519 · Simon Wickens Medication was administered to a patient with a known allergy without appropriate senior medical advice, and the consent obtained for this treatment …	South East Surrey	Frimley Park Hospital	1/1
25 Nov 2014	Stephen Mayoll 2014-0515 · David Horsley The hospital failed to re-assess out-patients for DVT risk according to policy and experienced delays in making fracture clinic notes available, risking …	South East Portsmouth & South East Hampshire	Portsmouth Hospitals NHS Trust	1/1
25 Nov 2014	Michael Harman 2014-0514 · Jacqueline Lake Inadequate checks were made on Mr. Harman's personal hygiene, and clear indicators of his deteriorating condition, unsuitable for independent living, were not …	East of England Norfolk	Centra Support	1/1
25 Nov 2014	Richard Turner 2014-0513 · Jacqueline Lake Employees developed complacency regarding health and safety due to routine work, exacerbated by a lack of standard procedures to remind them of …	East of England Norfolk	FALCON CRANE HIRE LIMITED	0/1
25 Nov 2014	Ryan Loughran, Katie Joyce, Muhanna Alhayany and Sophie Ryan-Palmer 2014-0520 · ME Hassell Deficient governance and lack of a national lead for autologous stem cell transplants, coupled with absent national benchmarking data and inaccessible international …	London London Inner (North)	NHS England	1/1