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 289 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
17 Oct 2014	Stephen Atherton 2014-0451 · R Brittain The deceased required multiple, increasingly complex investigations, suggesting potential issues in initial diagnostic pathways or management of his condition.	London London Inner (North)	Barts Health NHS Trust NHS Tower Hamlets Clinical Commissioning … NHS England Tredegar Practice	0/4
14 Oct 2014	Alan Peck 2014-0444 · John Pollard Critical medication was not delivered due to an unconnected syringe driver and its subsequent failure to be transferred with the patient, depriving …	North West Manchester (South)	Tameside Hospital NHS Foundation Trust	0/1
13 Oct 2014	Mary Fenton 2014-0443 · John Pollard The coroner notes that there was no cardiology consultant on call after 5pm or at weekends, a lack of facilities for echocardiograms …	North West Manchester (South)	Department of Health and Social … Tameside Hospital NHS Foundation Trust	2/2
13 Oct 2014	Arsema Dawit 2014-0442 · Andrew Harris Police investigation suffered from premature offence classification, misleading record entries, and inadequate supervision of action plans. There was also a gap in …	London London (Inner South)	Metropolitan Police Service	1/1
13 Oct 2014	George Vickery 2014-0441 · David Horsley The decision to change a patient's treatment location without formally consulting or adequately considering the GP's request for home treatment jeopardised continuity …	South East Portsmouth & South East Hampshire	Southern Health NHS Trust	0/1
9 Oct 2014	Vincent Oliver 2014-0438 · Tony Brown A prison officer's failure to check a prisoner's well-being during unlocking, combined with a lack of recorded compliance with physical response requirements …	North East Northumberland (North)	HMP Northumberland	1/1
9 Oct 2014	Stephen Simpson 2014-0437 · Tony Brown The building's design, featuring smooth concrete stairs without non-slip surfaces and no lobby to cushion falls, creates a serious risk of injury …	North East Northumberland (North)	Home Group	0/1
9 Oct 2014	Sapper Dylan Gibson 2014-0436 · David Ridley The absence of master keys in the guard room for all camp buildings prevents prompt access in emergencies, potentially delaying critical interventions.	South West Wiltshire & Swindon	Ministry of Defence	1/1
9 Oct 2014	Tracey Rooke 2014-0435 · David Ridley Identified road signage issues, including location and condition, were not addressed by the Highways Authority, which delayed action until a Coroner's report …	South West Wiltshire & Swindon	Wiltshire Council	0/1
9 Oct 2014	Wade Patel 2014-0434 · Donald Coutts-Wood Outdated glass in older rented properties poses a significant safety risk as there is no legal requirement for landlords to proactively check …	East Midlands Leicester City & South Leicestershire	Department for Communities and Local …	1/1
8 Oct 2014	Chloe Siokos 2014-0439 · Andrew Walker Primary care lacks a clear framework and ready access to interpreters, and there is no system to flag relevant patient connections, impacting …	London London (North)	Department of Health and Social …	0/1
7 Oct 2014	Zakariyya Clark 2014-0440 · Nicola Mundy Significant deficiencies in A&E patient assessment and documentation, including vital signs and injury details, posed a risk to future patients if not …	Yorkshire and the Humber South Yorkshire (East)	Doncaster and Bassetlaw NHS Foundation …	0/1
7 Oct 2014	Ella Block 2014-0433 · Ian Arrow Opportunities for timely sepsis treatment in children may be missed because newly qualified clinicians struggle to identify this rare but fatal condition.	South West Plymouth, Torbay & South Devon	Plymouth Hospitals NHS Trust	0/1
7 Oct 2014	Elouise Winship 2014-0431 · John Gittins There is no documented standard practice for regular fetal heart auscultation after opiate administration or for further maternal examinations following a change …	Wales North Wales (East & Central)	Betsi Cadwaladr University Health Board	0/1
7 Oct 2014	Timothy Cowen 2014-0430 · John Gittins New training on procedures is not mandatory for all staff, and the Acute Liaison Nurse role, crucial for patient support, lacks adequate …	Wales North Wales (East & Central)	Betsi Cadwaladr University Health Board	0/1
6 Oct 2014	Kai Lambe 2014-0557 · Andrew Haigh Inadequate safety measures and insufficient warning signage at a dangerous weir and salmon chute put children playing in the area at significant …	West Midlands Staffordshire South	Environment Agency Headquarters	0/1
6 Oct 2014	Matthew Flatman 2014-0429 · David Horsley The slow process of proscribing the "legal high" MDAI/Gogaine poses a fatal risk, particularly to users with cardiac problems, requiring accelerated action.	South East Portsmouth & South East Hampshire	Home Office	0/1
3 Oct 2014	John Andrews 2014-0426 · Elizabeth Gray Inadequate discharge planning and communication for a vulnerable patient, leading to them returning home without necessary care arrangements, heating, or groceries.	South East Milton Keynes	Milton Keynes Hospital	0/1
2 Oct 2014	Gavin Bradley, Mark Thorpe and Darren Thorpe 2014-0424 · Eric Armstrong Unsafe weir design lacks specific channels for kayaks and suitable upstream landing areas, coupled with insufficient warnings, risking water users' safety.	North East Northumberland (South)	Northumbria Water	0/1
2 Oct 2014	Mr Pether 2014-0432 · Nadia Persaud Inadequate monitoring and assessment of a patient's wound, delayed identification of infection, and insufficient re-consideration of treatment options despite deteriorating clinical condition.	London London (East)	Barking, Havering and Redbridge University …	0/1