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 291 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
18 Sep 2014	Janet Goodacre 2014-0408 · Lydia Brown The Trust submitted an inaccurate and flawed investigation report with incorrect root causes, failing to identify actual service difficulties and delaying communication …	East Midlands Leicester City & South Leicestershire	University Hospitals of Leicester NHS …	1/1
15 Sep 2014	George Palmer 2014-0407 · Martin Fleming Discharge follow-up mechanisms were inadequate for patients transferring areas, leading to a lack of continuity of support, and follow-up letters for non-contact …	South East Surrey	Community Mental Health Recovery Services	1/1
12 Sep 2014	Evelyn Smith 2014-0406 · R Brittain Inaccurate vital sign recording and lack of clinician knowledge regarding pediatric early warning and croup severity scoring systems hindered early recognition of …	West Midlands Warwickshire	NHS England NHS England Royal College of Emergency Medicine Royal College of Paediatrics and …	0/4
12 Sep 2014	Barbara Cooke 2014-0405 · Caroline Sumeray Severe understaffing at a care home caused patient neglect, poor infection control, and lacking external nurse communication protocols. The hospital also had …	South East Isle of Wight	Care Quality Commission Isle of Wight Adult Safeguarding … St Mary’s Hospital Waxham House Residential Care Home	0/4
12 Sep 2014	Clive Turner 2014-0404 · John Gittins Hospital staff lacked knowledge of pre-hospital pain relief, there were no clear policies for overnight patient discharge, and senior clinical oversight was …	Wales North Wales (East & Central)	Betsi Cadwaladr University Health Board	1/1
12 Sep 2014	Ian Page 2014-0403 · Jonathan Layton Communication failures post-handover, lack of falls risk assessment, unavailability of a low bed, and inadequate staffing levels for high-need patients contributed to …	Wales Carmarthenshire & Pembrokeshire	Withybush General Hospital	0/1
12 Sep 2014	Sybil Roberts 2014-0402 · John Gittins A patient's declining condition and mobility were inadequately assessed for falls risk upon admission and after hospital discharge, leading to repeated falls …	Wales North Wales (East & Central)	Manor Park Residential Home	0/1
11 Sep 2014	Ann Wells 2014-0401 · Jacqueline Lake A light switch and emergency call switch were positioned beyond the reach of a frail patient from her bed, and no risk …	East of England Norfolk	Norfolk and Suffolk NHS Foundation …	0/1
11 Sep 2014	Nicholas Megginson 2014-0400 · Andrew Barkley Patients discharged post-surgery received inconsistent advice, both oral and written, regarding venous thromboembolism risks and critical signs requiring urgent medical attention.	Wales Powys, Bridgend & Glamorgan Valleys	Cwm Taf Morgannwg University Health …	0/1
10 Sep 2014	Gloria Foster 2014-0399 · Richard Travers Insufficient protocols for staff support and training during care provider closures, unclear team leader supervision, and poor management of communication channels with …	South East Surrey	Care Quality Commission Surrey County Council	1/2
10 Sep 2014	James Clarke 2014-0398 Carers provided seriously inadequate supervision, failing to check a vulnerable patient with a tracheotomy overnight, and received only theoretical training without practical …		Care Quality Commission	1/1
9 Sep 2014	Rosalind Adshead 2014-0427 · John Pollard A severely ill patient was unsafely transferred between hospitals in the early hours, a practice deemed unsafe by consultants, exacerbated by ambulance …	Manchester (South	N.W.A.S. NHS Trust Stockport NHS Foundation Trust	0/2
9 Sep 2014	Joyce Nelson 2014-0397 Significant delays in doctor assessment and imaging results in the Emergency Department, caused by national shortages of emergency medicine doctors and radiologists, …		Department of Health and Social …	0/1
8 Sep 2014	Anthony Offord 2014-0396 · Peter Dorries Emergency medical dispatch staff lacked training on respiratory distress signs. Protocols were absent for ambulance crew "stand-offs," considering alternative support, or managing …	Yorkshire and the Humber South Yorkshire (West)	Department of Health and Social … Yorkshire Ambulance Service	1/2
5 Sep 2014	Kane Sparham-Price 2014-0463 · John Pollard Pay-day lenders cleared the deceased's bank account, leaving him destitute with no funds, highlighting a need for a statutory minimum amount to …	North West Manchester (South)	Financial Conduct Authority	1/1
5 Sep 2014	Peter White 2014-0395 · Tom Osborne Early Warning Observation Charts were incorrectly completed, triggers ignored, and observations unchecked by qualified staff, leading to missed opportunities for critical interventions. …	South East Milton Keynes	Milton Keynes Hospital	0/1
4 Sep 2014	Gillian Crossley 2014-0394 · Catherine Mason Inadequate documentation, insufficient patient observation and monitoring, poor discharge planning, and a breakdown in communication between care providers were identified.	East Midlands Leicester City & South Leicestershire	University Hospitals Leicester	0/1
4 Sep 2014	Anne Sandever 2014-0393 · Dr Samuel Bass A patient experienced a severe lack of nursing care, poor communication leading to unmanaged diabetes, and was left without vital intravenous fluids …	East of England Cambridgeshire (South & West)	Hinchingbrooke Hospital	1/1
3 Sep 2014	Richard Barker, Ryan Bramwell and Robert Graham 2014-0462 · John Pollard Road safety was compromised by vehicles having 'better' tyres on the front, which contributed to aquaplaning. Additionally, police officers were unaware of …	North West Manchester (South)	Department for Transport Derbyshire	0/2
3 Sep 2014	Yohannes Kidane 2014-0392 · Louise Hunt Insufficient night staffing on prison healthcare wards compromised effective ACCT observations and overall prisoner care. Additionally, staff were not taking breaks, impacting …	West Midlands Birmingham & Solihull	Birmingham and Solihull Mental Health … Birmingham Prison	2/2