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 290 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
2 Oct 2014	Lexi Branson 2014-0428 · Trevor Kirkland A complete absence of national or local standards for re-homing stray dogs, assessing dog suitability, applicant suitability, or verifying kennel re-homing policies.	East Midlands Rutland & North Leicestershire	Department for Environment Food and … Leicester City Council Leicestershire Local Safeguarding Board Ministry of Justice	2/4
30 Sep 2014	Derek Hawkins 2014-0425 · Catherine McKenna The risk assessment tool relies on subjective practitioner judgment, lacks objective rating, and may lead to less experienced staff failing to identify …	North West Manchester (North)	Not Listed	0/1
30 Sep 2014	Victoria Rhodes 2014-0422 · Thomas Osborne High speed limits on grid roads in Milton Keynes where pedestrians have access, necessitating a review of the existing speed limits for …	South East Milton Keynes	Milton Keynes Council	1/1
29 Sep 2014	Tiya Chauhan 2014-0575 · Fiona Wilcox Childcare settings and parents are unaware of the choking risks posed by raw jelly cubes, with packets lacking adequate warnings and supervision …	London London Inner (West)	Department for Education Food Standards Agency Ofsted Local Government Association	3/4
29 Sep 2014	Christopher Davies 2014-0420 · John Gittins Insufficient communication to patients and staff regarding the interaction between clozapine, caffeine, and smoking, as well as warning signs of toxicity.	Wales North Wales (East & Central)	Betsi Cadwaladr University Health Boar	0/1
26 Sep 2014	Dorothy Clarkson 2014-0465 · Simon Jones Inadequate procedures for providing food to residents needing specific preparations and assistance, alongside a lack of appropriate professional development training for nursing …	North West Preston & West Lancashire	Care Quality Commission MPS Investments Ltd Nesbit Law Group [Solicitors for …	0/3
26 Sep 2014	Emmanuel Akinmuyiwa 2014-0421 · Louise Hunt The absence of a clear regional protocol for sickle cell disease management led to staff lacking knowledge of crisis symptoms and necessary …	West Midlands Birmingham & Solihull	Birmingham and Solihull Clinical Commissioning … Commissioning groups NHS England	0/3
24 Sep 2014	Isa Mushtaq 2014-0423 · Sara Lewis A critical lack of detailed national guidance for antepartum CTG assessment, interpretation, and intervention, leading to inconsistent and potentially unsafe management of …	North West Manchester (City)	Department of Health and Social … National Institute for Health and … Royal College of Gynaecologists and …	0/3
24 Sep 2014	Leonard Hudson 2014-0419 Multiple failures in pressure ulcer prevention and management, including policy non-adherence, inadequate documentation, late referrals, inconsistent care, and poor record keeping.	North East Sunderland	City Hospitals Sunderland NHS Foundation …	0/1
24 Sep 2014	Caroline Carter Crowther 2014-0418 Contradictory policies and training regarding compelling psychiatric patients to hospital, with paramedics uncertain about their authority to physically coerce grievously ill patients.	West Midlands Worcestershire	West Midlands Ambulance Trust	0/1
24 Sep 2014	Jake Johnson 2014-0417 Unrestricted public access to a motorway due to open steps and damaged boundary fencing, compounded by a lack of warning signs, especially …	North West Cheshire	Highways Agency	0/1
22 Sep 2014	Martin Dean 2014-0416 Inadequate adherence to hand hygiene by visitors on a Critical Care Ward, directly increasing the risk of infection to vulnerable patients.	North West Manchester West	Salford Royal Foundation Trust	0/1
22 Sep 2014	Jerome Gonnet 2014-0415 Unclear and insufficient signage for a 'no entry' slip road, with temporary warnings frequently being ineffective, leading to repeated instances of drivers …	North East Teesside	A-One+ Cleveland Police Roads Policing Unit	1/2
19 Sep 2014	Linda Rignall 2014-0414 · Veronica Hamilton-Deeley A patient's significant clinical deterioration, recorded on a NEWS chart, was not reported to a doctor or assessed promptly, risking future deaths.	South East Brighton & Hove	Royal Sussex County Hospital	0/1
19 Sep 2014	Satheeskumar Mahatheaven 2014-0412 · ME Hassell Failures in information sharing, multi-agency communication procedures, and inadequate training contributed to an accident within prison services.	London London Inner (North)	HMP Pentonville	1/1
19 Sep 2014	Aaron Plowman 2014-0411 · Lorna Tagliavini Unblocked access points to commercial unit roofs under railway arches allow unauthorized persons to climb from the street, posing a safety risk.	London London (Inner South)	Network Rail	0/1
18 Sep 2014	Beatrice Gatt 2014-0566 · Anne Pember A critical antipsychotic medication was not administered due to a transfer error between medication sheets, highlighting a lack of formal training for …	East Midlands Northampton	Shire Lodge Nursing Home	0/1
18 Sep 2014	Marjorie Phillips 2014-0413 · John Pollard The patient's fall from a hoist was attributed to the sling's tendency to "bagging" at the sides, creating a fall risk if …	North West Manchester (South)	Sunrise Medical Limited Faversham Nursing Home	1/2
18 Sep 2014	Brian Dalrymple 2014-0410 · Jeremy Chipperfield The report identifies a lack of awareness among detention staff regarding indicators of mental health issues, a failure to act on recorded …	London West London	GEOAmey Nestor Primecare Serco Home Office	1/5
18 Sep 2014	William France 2014-0409 · Michael Rose Railway crossing barriers malfunctioned due to a single-arm treddle, causing long delays. Drivers also faced obstructed visibility and a poorly located emergency …	South West Somerset (West)	Network Rail	0/1