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 288 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
27 Oct 2014	Cherylin Norrell-Goldsmith 2014-0470 · Richard Travers Concerns include accessible ligature points in cells, insufficient multi-disciplinary input in ACCT reviews, and critical medical information not being readily available to …	South East Surrey	HMP Downview Lord Chancellor Surrey and Borders Partnership NHS … Virgin Care	1/4
27 Oct 2014	Jackson Mitchell 2014-0468 · Jacqueline Lake The death was caused by liver damage from parenteral nutrition extravasation, likely due to a low-lying umbilical venous catheter, highlighting risks associated …	East of England Norfolk	NHS England Norfolk and Norwich University Hospital … Queen Elizabeth Hospital King’s Lynn …	1/3
27 Oct 2014	Betty Smith 2014-0467 · Rachel Redman Inadequate pre-operative assessment and failure to secure an HDU bed for a high-risk patient were major concerns. Insufficient ITU bed capacity due …	South East Kent (South East & Central)	East Kent Hospitals University NHS …	0/1
27 Oct 2014	Philip Allen 2014-0466 · Philip Barlow The GP surgery's repeat prescription system failed to prevent the continued prescribing of a medication after a specialist advised stopping it, indicating …	London London (Inner South)	Eltham Palace Surgery	1/1
24 Oct 2014	Eliza Bashir 2014-0461 · Simon Nelson Concerns focus on easily accessible button batteries in products not classified as toys, lack of national awareness regarding ingestion risks, and medical …	North West Manchester (North)	Central Manchester University Hospitals NHS … Department of Health and Social … Oldham Metropolitan Borough Council	1/3
24 Oct 2014	Hilda Cole 2014-0460 · Andrew Haigh The pendant alarm provider failed to adequately inform customers about additional safety features, specifically the option to link to fire alarms, creating …	West Midlands Staffordshire (South)	Care Quality Commission Welbeing	0/2
23 Oct 2014	Sonielia Holmes 2014-0459 · Thomas Osborne The report identifies that doctors had difficulty contacting the Haematology Department at the Hospital and haematologists failed to respond to messages requesting …	East of England Bedfordshire & Luton	Bedford Hospital NHS Trust	0/1
23 Oct 2014	Phyllis Kerry 2014-0457 · Heidi Connor There is a lack of clear, communicated guidelines for managing patients with intra-cerebral bleeds while on Warfarin, leading to uncertainty about clinical …	East Midlands Nottinghamshire	Nottingham University Hospitals NHS Trust	2/1
23 Oct 2014	Maria Stubbings 2014-0458 · Caroline Beasley-Murray Gaps in the system allow individuals convicted of murder abroad to enter the UK without conditions or local police notification, lacking retrospective …	East of England Essex	Ministry of Justice Select Committee, Home Affairs Home Office Treasury Solicitors	0/4
21 Oct 2014	Elsie Plumb 2014-0455 · Maria Voisin The Royal College of Obstetricians and Gynaecologists' guideline on preventing neonatal Group B Strep disease is ambiguously worded regarding the timing and …	South West Avon	Royal College of Obstetricians and …	0/1
21 Oct 2014	Mary Stroman 2014-0454 · David Ridley A child's recommended long-term therapeutic placement was delayed and ultimately overturned by Children's Services, despite multi-agency support, due to a perceived failure …	South West Wiltshire & Swindon	Haringey Council	1/1
20 Oct 2014	Samuel Duckworth 2014-0456 · Andrew Harris The ease of purchasing prescription-only drugs like Diazepam via the internet without medical supervision creates an ongoing risk for vulnerable individuals.	London London (Inner South)	Department of Health and Social …	1/1
17 Oct 2014	Kirsty Pritchard 2014-0565 · Zafar Siddique There were communication failures between community and inpatient teams regarding the patient's post-discharge contacts, delaying self-harm risk assessment. Deficiencies also existed in …	West Midlands Black Country	Black Country NHS Partnership Trust	1/1
17 Oct 2014	Yaser Saleh 2014-0453 · Andrew Harris The GP's computer system only prompts reviews for patients on regular prescriptions, failing to identify those with chronic diseases like asthma who …	London London (Inner South)	Department of Health and Social … EMIS Health Iveagh Surgery	0/3
17 Oct 2014	William Anderson 2014-0452 · Melanie Williamson Prison staff lacked effective vigilance over inmate gatherings involving drugs/alcohol, were insufficiently trained in breathalyser use, and failed to adequately record inmate …	Yorkshire and the Humber West Yorkshire (East)	Solicitors Leeds Community Healthcare NHS Trust Solicitors National Offender Management Service	0/4
16 Oct 2014	John Bird 2014-0450 · ME Hassell The care home manager failed to ensure staff were familiar with residents' falls risk assessments and care plans, leading to an untrained …	London London Inner (North)	Hawthorn Green Care Home Sanctuary Care Limited	0/2
16 Oct 2014	Roger de Klerk 2014-0448 · Selena Lynch Poorly designed bicycle lanes and confusing signage at a junction create significant dangers for cyclists due to tramlines, forcing unsafe crossing angles …	London London (South)	London Borough of Croydon	1/1
16 Oct 2014	David Thomson 2014-0447 · Andre Rebello E-cigarette batteries charged via universal micro USB ports are at risk of explosion if an incompatible charger supplies the wrong current.	North West Liverpool	Department for Business, Innovation and …	0/1
15 Oct 2014	Seweryn Glowinski 2014-0446 · Geraint Williams Serious communication breakdown between prison units, incorrect documentation due to "cutting and pasting" prisoner information, and senior staff unawareness of segregation policies …	West Midlands Worcestershire	HMP Long Larkin	0/1
15 Oct 2014	Lucasz Lewandowski 2014-0445 · Lisa Hashmi The report identifies concerns regarding the timeliness of the police response, communication gaps between agencies, use of the Mental Health Act due …	North West Manchester (North)	Greater Manchester Police Green Surgery MEDACS Healthcare	2/3