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 293 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
11 Aug 2014	Aaron Vranas 2014-0376 · Tom Osborne Fragmented care for patients with co-occurring psychiatric illness and ADHD due to treatment at geographically separate hospitals creates significant management difficulties.	East of England Bedfordshire & Luton	Bedfordshire Clinical Commissioning Group	1/1
8 Aug 2014	Sean Brock 2014-0381 · Tom Osborne A significant reduction in prison officer numbers at HMP Woodhill directly compromises prisoner safety and poses a risk to lives.	South East Milton Keynes	National Offender Management Service	1/1
7 Aug 2014	Noleen McPharlane 2014-0370 · ME Hassell Inadequate mental health care included a failure to directly assess suicidal ideation or illicit drug use, short sessions, and a lack of …	London London North (Inner)	Camden and Islington NHS Foundation …	1/1
7 Aug 2014	Vijay Sonagara 2014-0364 · Philip Barlow Critical medical information was not consolidated, as the patient had multiple unamalgamated records and a temporary file, leading to treating doctors being …	London London (South Inner)	Barts Health NHS Trust	0/1
6 Aug 2014	Lee Friend 2014-0372 Insufficient visibility for temporary traffic lights and absent guidance for placement near blind bends created road safety risks, compounded by a lack …		Department for Transport Reigate and Banstead Council Surrey Police Sutton and East Surrey Water …	0/4
6 Aug 2014	Charles Pierson 2014-0336 · ARW Forrest The deceased was able to meet the vision standard set for drivers by the DVLA according to a practitioner registered with the …	South Leicestershire	Buckinghamshire Healthcare NHS Trust General Optical Council	1/2
6 Aug 2014	Jack Dulson 2014-0365 · Louise Hunt The GP practice lacked a system for promptly reviewing abnormal blood test results and initiating patient follow-up, causing critical delays in treatment.	West Midlands Birmingham & Solihull	Surgery Chesterton	0/1
6 Aug 2014	Vivian Hunt 2014-0363 · Andrew Barkley Neurological observations were critically missed for several hours following a patient's two falls, despite visible injuries.	Wales Powys, Bridgend and Glamorgan	Cwm Taff Health Board	1/1
6 Aug 2014	Martin Hill 2014-0362 · John Ellery Critical abdominal X-ray findings indicating small bowel obstruction were overlooked, leading to an inappropriate discharge and delayed re-admission. Additionally, prescribed discharge medication …	West Midlands Shropshire, Telford & Wrekin	Shrewsbury and Telford Hospital NHS …	0/1
5 Aug 2014	John Wilsher 2014-0360 An inaccurate discharge letter and a lack of communication regarding pre-existing concerns about a care home's suitability led to an inappropriate patient …		Norfolk and Norwich University Hospital … Norfolk Community Health and Care … Norfolk County Council	2/3
5 Aug 2014	Clare Bain 2014-0359 Paramedics lacked awareness that Naloxone's antagonism duration might be shorter than Methadone's respiratory depressant effects, risking patient deaths due to inadequate repeat …		South West Ambulance Service	1/1
4 Aug 2014	Michael Holgate 2014-0357 The tunnel lacked communication facilities and mandatory safety equipment like life jackets or helmets. Insufficient safety information was provided to all canal …		Canal and River Trust	1/1
4 Aug 2014	Carol Walker 2014-0361 · David Hinchliff Hospitals lacked routine chemical thrombo prophylaxis and formal risk assessment for venous thromboembolism in low-risk patients with conservatively treated lower limb injuries.	Yorkshire and the Humber West Yorkshire (Eastern)	Harrogate District Hospital	0/1
1 Aug 2014	Gerald Werrett 2014-0355 Catastrophic failures in chest drain insertion included unlabelled and misinterpreted chest X-rays, incomplete review of images, and a lack of patient examination …		College of Emergency Medicine Department of Health and Social … British Thoracic Society Royal College of Anaesthetists	4/4
31 Jul 2014	Nadine Thurman 2014-0303 · Robin Balmain The psychiatric assessment was flawed due to a relative being excluded and the patient being inappropriately prompted about solitary assessment.	West Midlands Black Country	Dudley and Walsall NHS Mental …	0/1
31 Jul 2014	Edna Smither 2014-0353 · John Pollard Inadequate staff First Aid training, a locked emergency exit, and a lack of calm leadership during an emergency were compounded by significant …	North West Manchester (South)	Harbour Healthcare United Care (North) Limited	0/2
31 Jul 2014	John Shelley 2014-0352 · Jonathan Layton The inquest revealed unstated circumstances that pose a continued risk of future deaths if action is not taken.	Wales Carmarthenshire & Pembrokeshire	Hywel Dda University Health Board	1/1
31 Jul 2014	Antonio Allen 2014-0351 · John Pollard Midwives were repeatedly uncontactable for an overdue home birth, leading to the delivery being performed by family members before their eventual arrival.	North West Manchester (South)	Central Manchester NHS Foundation Trust	1/1
31 Jul 2014	Toni Skillington 2014-0369 · ME Hassell The dispatch system inadequately captured methadone overdoses and patient solitude. Welfare checks were not actioned, resulting in a three-hour delay in paramedic …	London London North (Inner)	London Ambulance Service NHS Trust	0/1
30 Jul 2014	Lynn Gormly 2014-0356 The Queensgate Car Parks' low walls are ineffective in preventing suicides and pose a risk to pedestrians. Design improvements like higher barriers, …		Hammerson Plc Pelican Partners Ltd Peterborough City Council	1/3