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 294 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
30 Jul 2014	Anne Whitworth 2014-0358 Incompatible computer systems prevented out-of-hours doctors from accessing GP records, leading to a missed opportunity to escalate urgent treatment.		Local Care Direct organisation Sheridan Teal House	0/2
30 Jul 2014	Christopher Royal 2014-0354 · Lydia Brown The nursing home had an unreliable patient observation system, expired First Aid certifications, staff incompetence in CPR, and concerns regarding care quality …	East Midlands Leicester City & South Leicestershire	Baron’s Park Nursing Home	1/1
30 Jul 2014	Monique Whitbread 2014-0368 · ME Hassell A gastric bypass procedure inadvertently led to hernia strangulation and death in a bariatric patient. The surgeon's revised practice of using sleeve …	London London North (Inner)	University College Hospital	0/1
29 Jul 2014	Gary Million 2014-0348 · Andrew Tweddle Critical delays occurred in locating a patient due to ambulance service staff lacking training on finding callers with incomplete address information and …	North East County Durham & Darlington	North East Ambulance Trust	0/1
28 Jul 2014	Suzanne Cammell 2014-0579 · Darren Salter Critical high-risk information about a patient's previous suicide attempt, recorded on police databases, was not effectively communicated between police forces or to …	South East Oxfordshire	Thames Valley Police Gloucestershire Constabulary	1/2
28 Jul 2014	Hope Evans 2014-0569 · Colin Phillips Critical patient history, including IVF treatment abroad and ESBL E. coli infection, was not effectively transferred between hospitals. This led to inappropriate …	Wales Swansea Neath & Port Talbot	Welsh Government	0/1
28 Jul 2014	Faye Rippon 2014-0349 · Dr Elizabeth Earland Current protocols for late terminations of pregnancy (21/40 gestation) are inadequate as they lead to live births, causing distress and conflicting with …	South West Exeter & Greater Devon	North Devon District Hospital	0/1
28 Jul 2014	Frances Andrade 2014-0347 · Richard Travers Vulnerable witnesses require clear advice on psychiatric counselling and timely explanations of trial proceedings. Additionally, better measures are needed to secure prescription …	South East Surrey	Director of Public Prosecutions Surrey and Borders Partnership NHS …	1/2
25 Jul 2014	Edna Bulmer 2014-0346 · Mary Burke The coroner noted inconsistencies in the documented level of falls risk and that measures to minimise risk were not implemented promptly. It …	Yorkshire and the Humber West Yorkshire (West)	Dovecote Lodge	0/1
25 Jul 2014	Clare Cooper 2014-0345 · Karen Henderson The report identifies poor GP documentation, a lack of robust assessment of presenting signs and symptoms, and a lack of routine vital …	South East Surrey	East Surrey Clinical Commissioning Group Eating Disorder Services for Adults Royal College of Pathologists Royal College of Physicians	4/6
25 Jul 2014	Stephen Amer 2014-0344 · Edward Thomas Concerns relate to the adequacy of support for sole carers, comprehensive mental health risk assessment, and the balance between patient wishes and …	East of England Hertfordshire	Hertfordshire County Council	1/1
25 Jul 2014	Nathan Healer 2014-0343 · Derek Winter A newborn's severe condition was not appreciated, leading to a missed opportunity for timely blood glucose testing despite existing hospital and NICE …	North East Sunderland	Department of Health and Social …	1/1
25 Jul 2014	Charles Lawrence 2014-0342 · David Horsley The care home lacks a critical protocol to ensure a doctor examines residents who experience multiple falls within a 24-hour period, indicating …	South East Portsmouth & South East Hampshire	Alexandra Rose Care Home	1/1
25 Jul 2014	Donna Kirkland 2014-0341 · Jason Pegg Patients had unlimited and unsupervised access to alcohol-based hand sanitising gels, enabling decanting and storage in rooms. Staff lacked awareness of the …	West Midlands Coventry	Coventry and Warwickshire Partnership Trust Department of Health and Social …	2/2
24 Jul 2014	Graham Darby 2014-0367 · Gail Elliman A crucial communication breakdown occurred as a patient's explicit suicide threat regarding eviction was not adequately flagged to the housing provider by …	London London North	East London NHS Foundation Trust Family Mosaic Hackney Alcohol Recovery Centre	0/3
23 Jul 2014	John Thorpe 2014-0340 · Paul Cooper The deceased was inappropriately asked to self-refer to mental health services, and crucial follow-up was absent. Doctors failed to adequately consider the …	East Midlands South Lincolnshire	East Midlands Local Education and … Lincolnshire East Clinical Commissioning Group	0/2
23 Jul 2014	Kenneth Paul 2014-0338 · ARW Forrest The delivery vehicle involved in the collision lacked an automatic audible reverse warning device. There is no legislative requirement for such safety …	East Midlands South Lincolnshire	Department for Transport	0/1
23 Jul 2014	Graeme Kidd 2014-0337 · Jacqueline Lake Locum doctors lacked access to vital electronic records and awareness of mental health services, while GPs faced referral barriers due to mandatory …	East of England Norfolk	Norfolk and Suffolk NHS Foundation …	0/1
22 Jul 2014	Yahya Khan 2014-0334 · Edward Thomas The coroner raised concerns about the diagnostic challenges of acute appendicitis in very young children, emphasizing the need for improved recognition pathways …	East of England Hertfordshire	National Institute of Health and …	0/1
22 Jul 2014	Molly Keen 2014-0336-wp24459 · Richard Hulett Inconsistent use of customised growth charts and poor recording of fundal height measurements between two NHS trusts obscured fetal growth assessment. Crucially, …	South East Buckinghamshire	West Hertfordshire Hospitals NHS Trust	0/1