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 292 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
3 Sep 2014	Hilda Thompson 2014-0391 · Martin Fleming There was a significant failure in falls risk assessment upon admission, with no further review for 10 days, leaving the patient vulnerable. …	South East Surrey	East Surrey Hospital Trust	0/1
2 Sep 2014	Peter Stanley 2014-0390 · Peter Dorries A lack of formal 'step-down' policy exists for young people discharged from or failing to engage with Adult Mental Health Services. Additionally, …	Yorkshire and the Humber South Yorkshire ( West)	Department for Education GEOAmey South Yorkshire Police Youth Justice Board	1/4
1 Sep 2014	Thomas Taylor 2014-0388 · ME Hassell The ward lacked clear leadership and support, there was no protocol for lost notes and drug charts, and there seemed to be …	London London Inner (North)	Royal Free London NHS Trust	0/1
29 Aug 2014	Jude Kliem 2014-0464 · Ian Arrow The coroner identified a critical breakdown in communication as a key concern.	South West Plymouth, Torbay & South Devon	Department of Health and Social …	1/1
29 Aug 2014	Linda Lloyd 2014-0389 · Alan Wilson Prior to review, concerns existed regarding triage being performed by non-senior nurses without adequate training, and departmental policy failing to consistently consider …	North West Blackpool & Fylde	Blackpool Teaching Hospital NHS Foundation …	0/1
29 Aug 2014	Irshad Ali 2014-0387 · ME Hassell The report identifies missing records of required nursing observations, a failure to complete neurological observations before discharge as stipulated, and miscommunication regarding …	London London Inner (North)	Barts Health	1/1
29 Aug 2014	Stephen Farrar 2014-0386 · Tom Osborne There was no formal risk assessment completed when Mr Farrar was first admitted to Woodhill Prison, despite risk factors; there is no …	South East Milton Keynes	Ministry of Justice Secretary of State for Health	1/2
28 Aug 2014	Lauren Barfoot 2014-0385 · Lorna Tagliavini Failures in information sharing between Social Services and the Missing Person's Unit led to an inadequate risk classification and an ineffective search …	London London (Inner South)	Bexley Social Services Ethelbert’s Children’s Services Metropolitan Police Service	4/3
26 Aug 2014	Iris Grimwood 2014-0384 · ARW Forrest Inadequate nursing staff levels, compounded by recruitment and training difficulties, led to significant mistakes in patient care, including incorrect medication application and …	East Midlands South Lincolnshire	United Lincolnshire Hospitals NHS Trust	0/1
22 Aug 2014	Martin Hill 2014-0382 · Veronica Hamilton-Deeley No specific concerns were detailed in the provided text for this report.	South East Brighton & Hove	Brighton and Sussex University Hospitals	1/1
22 Aug 2014	Tessa Summers 2014-0383 · David Horsley Social workers failed to record the rationale for downgrading a patient's self-harm risk, and Adult Social Services lacked sufficient training and support …	South East Portsmouth & South East Hampshire	Hampshire County Council	1/1
21 Aug 2014	Herbert Chandler 2014-0570 · Rachel Redman Multiple clinical management failures included inappropriate prescribing, delayed chest drain insertion, and poor communication of consultant findings. The Medical Registrar failed to …	South East Kent (Central & South East)	East Kent Hospital University NHS …	0/1
21 Aug 2014	Joanna Greensmith 2014-0380 · Wendy James Road safety was compromised by a failure to treat the surface according to adverse weather plans and by the Route Steward not …	Wales Gwent	South Wales Trunk Road Agent	1/1
20 Aug 2014	George Stone 2014-0379 · David Horsley National guidelines for antidepressant warnings, specifically for Venlafaxine, fail to include the rare but severe risk of seizures, potentially leaving patients uninformed …	South East Portsmouth & South East Hampshire	National Patient Safety Agency	0/1
18 Aug 2014	Jeffrey Gash 2014-0377 · Andrew Tweddle Crisis Team failures included inadequate telephone assessment training, no clear policy for declining home visits, and insufficient exploration of new symptoms leading …	North East County Durham & Darlington	Tees, Esk and Wear Valleys …	1/1
14 Aug 2014	Olegs Sulaimonovs 2014-0375 · Margaret Jones Road safety was severely compromised by a lack of footpaths, suitable lighting, and speed restrictions in a populated area. Additionally, there was …	West Midlands Staffordshire (South)	Billington Farm Staffordshire County Council Staffordshire Police The Chief Coroner	1/4
14 Aug 2014	Thomas Warren 2014-0378 · Andrew Harris The employing Trust failed to adequately vet a locum doctor, missing critical information about previous concerns and investigations from other healthcare bodies, …	London London (Inner South)	Department of Health and Social … General Medical Council NHS England Lewisham and Greenwich NHS Trust	2/4
14 Aug 2014	Nicola Marsden 2014-0373 A critical brain scan was misinterpreted by a general radiologist instead of a neuro-radiologist, highlighting a failure to follow existing guidelines for …		NHS England	0/1
13 Aug 2014	Dorothy Robinson 2014-0374 A persistent risk of prescribing errors due to unaddressed patient intolerances/allergies remains, compounded by the absence of a crucial electronic prescribing system …		Royal United Hospital	1/1
12 Aug 2014	Dylan Rattray 2014-0371 · Nicola Jones The Snowdonia National Park Authority's failure to follow mountain rescue advice regarding misleading paths at the summit created a dangerous illusion of …	Wales North West Wales	Snowdonia National Park Authority	1/1