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 287 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
12 Nov 2014	Lorraine Sheridan 2014-0496 · Zafar Siddique Lack of adequate pedestrian signalisation at a specific road location, specifically an audible phase indication, has contributed to multiple collisions.	West Midlands Black Country	Sandwell Metropolitan Borough Council	0/1
12 Nov 2014	Patricia Mellor 2014-0491 · Jane Gillespie Despite detailed recommendations from a hospital regarding Long QT Syndrome and drug-related cardiac arrest risks during anaesthesia, regulatory bodies (MHRA, NICE) have …	East Midlands Nottinghamshire	Derby Hospitals NHS Foundation Trust Medicines and Healthcare Product Regulatory … National Institute for Health and … National Patient Safety Agency	0/4
11 Nov 2014	Amar Majid 2014-0495 · S McGovern Inadequate toilet checking procedures and confusion over protocols for prolonged occupancy led to a significant delay in discovering a person in distress.	West Midlands Coventry	Coventry City Council	0/1
11 Nov 2014	Mary Hallworth 2014-0487 · Joanne Kearsley A patient experiencing pain after a fall did not receive medical attention or assessment for a critical 24-hour period.	North West Manchester (South)	Home Instead Senior Care	0/1
11 Nov 2014	Rowena Golton 2014-0486 · Joanne Kearsley Critical shortages and significant waiting times for psychological services within crisis teams hinder adequate provision and timely access for vulnerable patients.	North West Manchester (South)	Manchester Clinical Commissioning Group Manchester Mental Health and Social …	1/2
11 Nov 2014	Beryl Walters 2014-0489 · Andrew Thompson Cyclizine, a medication with known cardiac risks in severe heart failure, was unnecessarily administered despite a safer alternative being available, posing avoidable …	West Midlands Black Country	College of Emergency Medicine National Institute for Clinical Excellence	0/2
10 Nov 2014	Mark Hancock 2014-0484 · Joanne Kearsley The coroner identified poor record-keeping, a lack of documented risk assessment, and an inappropriate environment for sensitive discussions with the deceased. There …	North West Manchester (South)	Priory Group	0/1
10 Nov 2014	Roseanne Cooke 2014-0485 · Joanne Kearsley Lack of inpatient psychological support, delayed/confused referrals, and critical communication breakdowns between family and care teams resulted in inadequate post-discharge support for …	North West Manchester (South)	5 Boroughs Partnership NHS Foundation …	1/1
10 Nov 2014	Myra Goldman 2014-0490 · Simon Nelson Inverted gate hinge pins concentrated excessive weight, failing to meet safety standards designed to prevent gates from being easily removed and ensure …	North West Manchester (North)	Health and Safety Executive Spaces and Places Limited British Standards Institute	1/3
7 Nov 2014	Colin Ireland 2014-0493 · David Hinchliff Critical medication doses were missed, VTE risk assessments were incomplete, and an inadequate hospital discharge summary failed to communicate essential treatment plans …	Yorkshire and the Humber West Yorkshire (West)	HMP Manchester Mid Yorkshire Hospitals NHS Trust High Security Prisons Group	0/3
7 Nov 2014	Barry Horrocks 2014-0492 · David Hinchliff A disabled prisoner's essential daily living needs were unmet as the prison environment lacked adaptations and no care provider took responsibility for …	Yorkshire and the Humber West Yorkshire (East)	Department of Health National Offender Management Service NHS England	0/3
5 Nov 2014	Santosh Muthiah 2014-0476 · Andrew Walker The inability to identify appliance details after severe fire damage hinders accurate defect pattern recognition, and inconsistent information sharing among Fire & …	London London (North)	Association of British Insurers Association of Manufacturers Of Domestic … Beko Plc British Standard's Institute	5/12
5 Nov 2014	William Davies 2014-0475 · ME Hassell Significant confusion exists among prison staff, including GPs, regarding emergency ambulance procedures and death verification, leading to inappropriate actions and potential fatal …	London London Inner (North)	Care UK Limited	1/1
4 Nov 2014	Rebecca Curtis-Small 2014-0483 · John Tomalin Beach signage is insufficient, lacking prominent display and specific warnings about variable riptide hazards, increasing public risk.	South West Exeter & Greater Devon	Maritime and Coastguard Agency North Devon District Council Parkdeane Holidays Royal National Lifeboat Institute	3/4
3 Nov 2014	Sandra Higham 2014-0479 · Henrietta Hill A highly fatal complication of atrial ablation, atrial-oesophageal fistula, is difficult to diagnose due to non-specific symptoms and low medical awareness within …	London London (Inner South)	Department of Health and Social … Public Health England The Heart Rhythm Society of …	3/3
31 Oct 2014	Christopher Ajayi 2014-0558-wp26761 · Sarah Ormond-Walshe A vulnerable patient with complex mental and physical health needs was discharged into unsupported accommodation without a care package or necessary medical …	London London (Inner South)	South London and Maudsley trust	1/1
31 Oct 2014	Maureen Ellett 2014-0473 · Veronica Hamilton-Deeley Initial A&E documentation was flawed, with critical patient information like blood pressure and Glasgow Coma Scale omitted from the front sheet.	South East Brighton and Hove	Brighton and Sussex University Hospital … Royal Sussex County Hospital	1/2
29 Oct 2014	Alan Evans 2014-0472 · Andrew Barkley The road layout with obscured views and permitted overtaking, combined with protruding "old style cats eyes," creates a significant highway safety risk …	Wales Powys, Bridgend & Glamorgan Valleys	Powys Highways Department	0/1
28 Oct 2014	Polly Carpenter 2014-0469 · Elizabeth Earland The hospital lacked clear, auditable records for patient risk assessments and observation levels on RIO, leading to staff being unaware of risks …	South West Exeter & Great Devon	Devon Partnership NHS Trust	1/1
27 Oct 2014	Agnes Hannan 2014-0573 · John Pollard Critical issues included unavailable hospital records, poor staff communication and handover, inadequate nursing observations, and a lack of consultant oversight. Delays in …	North West Manchester (South)	Tameside Hospital NHS Foundation Trust	1/1