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 286 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
24 Nov 2014	Sandra Bodrozic 2014-0560-wp25965 · ME Hassell Significant delays occurred in securing a hospital bed and arranging Mental Health Act assessments, exacerbated by a lack of urgency, protocol, and …	London London Inner (North)	Camden & Islington NHS Foundation …	0/1
24 Nov 2014	Gaenor Moore 2014-0512 · Martin Fleming Oxygen flow was lost due to an improperly engaged humidifier screw cap, exacerbated by the absence of an alarm on the concentrator …	South East Surrey	Dolby Vivisol Invacare Rehabilitation Salter Labs	3/3
24 Nov 2014	William Hafele 2014-0511 · Martin Fleming Inadequate training and communication between police and hospital staff on missing persons procedures led to critical information omissions, misclassification, and a complete …	South East Surrey	Surrey and Borders Partnership NHS … Surrey Police	2/2
24 Nov 2014	William Jackson 2014-0509 · D LI Roberts The hospital lacked a formal system to record specialist advice given during informal interactions, leading to critical advice being given without reviewing …	North West Cumbria (North & West)	Newcastle Foundation NHS Trust	1/1
24 Nov 2014	Lara Mamula 2014-0508 · Caroline Sumeray The ambulance service lacked critical understanding of Loeys-Dietz syndrome, failing to appreciate the severity of symptoms or stress the urgency of hospital …	South East Isle of Wight	Isle of Wight Ambulance Service Isle of Wight NHS Trust	0/2
24 Nov 2014	Harold Penny 2014-0507 · John Pollard The radiology department lacked a system to urgently report critical findings, such as a displaced urinary catheter causing a blockage, or to …	North West Manchester (South)	Tameside Hospital NHS Foundation Trust	1/1
21 Nov 2014	Tracey Bannister 2014-0506 · Zafar Siddique Patients discharged after ERCP surgery were not adequately advised to contact the surgical department directly for persistent symptoms, leading to delayed critical …	West Midlands Black Country	Walsall Healthcare NHS Trust	1/1
20 Nov 2014	Martin McCabe 2014-0505 · Andrew Barkley The hospital failed to conduct an updated falls risk assessment upon Mr. McCabe's admission, relying on an outdated assessment and omitting crucial …	Wales Powys, Bridgend & Glamorgan Valleys	Cwm Taf Health Board	0/1
19 Nov 2014	Leanne Gower 2014-0567 · Hassan Shah Police do not routinely share damage-only collision data with councils, hindering effective identification of hazardous road sections and informed highway maintenance decisions.	East Midlands Northampton	MGWSP Northamptonshire County Council Police Safer Roads Team	2/3
19 Nov 2014	George Werb 2014-0510 · Lydia Brown The lack of an effective child psychiatric bed bureau system caused significant delays and distant placements, leading to poor environment, limited family …	South West Exeter & Greater Devon	Devon Clinical Commissioning Group NHS England	1/2
17 Nov 2014	Peter Dorney 2014-0504 · Maria Voisin Nurses lacked mandatory training on Early Warning Scores (EWS), resulting in non-adherence to protocols critical for patient well-being and timely intervention.	South West Avon	Southmead Hospital	1/1
17 Nov 2014	Gladys Smith 2014-0502 · Melanie Williamson No specific safety concerns were detailed in the provided text.	Yorkshire and the Humber West Yorkshire (East)	Berrymans Lace Mawer LLP Hempsons Solicitors Leeds City Council Leeds Community Healthcare NHS Trust	0/9
17 Nov 2014	Elsie Mallalieu 2014-0501 · John Pollard Inappropriate ward placement with untrained staff and inadequate nursing notes led to missed observations and an incorrect DNAR decision, hindering escalation for …	North West Manchester (South)	Tameside NHS Foundation Trust	1/1
4 Nov 2014	Mark Hudson 2014-0478 · Alan Wilson Hospital procedures for urgent specialist care requests through the switchboard are insufficiently robust, risking unanswered or delayed responses that could harm patients.	North West Blackpool & Fylde	Blackpool Teaching Hospitals NHS Trust	1/1
14 Nov 2014	Marcus Szigetvari 2014-0503 · Sarah-Jane Richards The busy road during rush hour presented a high risk of drivers misjudging motorcycle headlights for distant cars, especially in poor conditions, …	Wales Powys, Bridgend & Glamorgan Valleys	Rhondda Cyon Taff Highways Department	1/1
12 Nov 2014	Neophytos Constantinou 2014-0498 · R Brittain Lack of clarity in procedures for arranging patient transportation led to necessary care being missed due to administrative issues.	London London Inner (North)	Chalfont Road Surgery Royal Free London NHS Foundation …	0/2
14 Nov 2014	Kirk Williams 2014-0499 · Sam Faulks A significant mismatch exists between police and A&E staff perceptions regarding the treatment of aggressive patients, including those with Excited Delirium, compounded …	North East Teesside	Cleveland Constabulary IPCC JCUH NEAS	3/5
14 Nov 2014	Dolores Hubbert 2014-0500 · Derek Winter Concerns were raised about the overall safety of a junction, specifically regarding speed restrictions and the frequency of grass cutting which could …	North East Sunderland	Sunderland City Council	1/1
13 Nov 2014	John Wright 2014-0494 · Andrew McNamara Trackside maintenance crews required frequent reminders for vigilance and comprehensive briefings on train routes and safe work methods. There was also a …	East Midlands Nottinghamshire	Frisbys Solicitors Kennedys Solicitors Network Rail Office of the Rail Regulator	0/6
12 Nov 2014	David Ince 2014-0497 · Sian Jones Emergency ambulance staff frequently fail to routinely hand over patient ECG traces to A&E personnel, leading to critical information being missed during …	North West Preston & West Lancashire	North West Ambulance Service NHS …	0/1