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 295 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
22 Jul 2014	Edward Devlin 2014-0335 · Crispin Oliver Nurses reportedly slid medication, including dangerous drugs, under locked cell doors, leading to uncertainty about patient consumption, compromised dispensing records, and risks …	North East County Durham & Darlington	Care UK HMP Durham National Offender Management Service Tees Esk Wear Valley NHS …	1/4
21 Jul 2014	Marcin Stoga 2014-0576 · Darren Salter Crucial information regarding a prisoner's overdose history was not available during initial assessment. Furthermore, prisoners with mental health risks are not routinely …	South East Oxfordshire	HMP Bullingdon	1/1
18 Jul 2014	Kathleen Cornthwaite 2014-0333 · Michael Singleton The concerns text provided for this report was incomplete, preventing a summary of specific issues.	North West Blackburn, Hyndburn & Ribble Valley	East Lancashire Healthcare NHS Trust	0/1
17 Jul 2014	Joshua Brown 2014-0289 · Rebecca Cobb The community health team lacked formal processes for family involvement and information sharing, especially when the patient withheld consent, hindering their ability …	South East North East Kent	Care Quality Commission Department of Health and Social … Kent and Medway NHS and …	1/3
17 Jul 2014	Michael Warren 2014-0330 · Peter Bedford Highway Inspectors received inadequate training and guidance for identifying road hazards, particularly from trees, and conducted superficial "drive-by" inspections, increasing risk to …	South East Berkshire	Bracknell Forest Borough Council Chartered Institute of Highways and …	0/2
16 Jul 2014	Julie Robertson 2014-0326 · Eleanor McGann Delayed blood availability due to the lack of a ward blood fridge and consistently poor record-keeping, with staff unaware of good practice, …	East of England Essex	Southend University Hospital	0/1
16 Jul 2014	Silvia Taylor 2014-0327 · Martin Fleming The service failed to act promptly on unsuccessful attempts to contact Mrs. Taylor and did not communicate these critical difficulties to her …	South East Surrey	Bracknell Forest Council Harmoni South East Woking Borough Council	1/3
15 Jul 2014	Stephen Church 2014-0331 · Ravi Sidhu A broken police command chain, insufficient staff knowledge of mental health protocols, and a critical lack of joint working between agencies delayed …	South East Berkshire	Berkshire Healthcare NHS Foundation Trust British Transport Police Royal Berkshire NHS Foundation Trust Thames Valley Police	3/4
15 Jul 2014	Ming Cheung 2014-0332 · S McGovern An unofficial pedestrian crossing point, used by many, had an obscured view due to a large sign, contributing to the incident and …	West Midlands Coventry	Tesco Plc	1/1
14 Jul 2014	Elaine Jobe 2014-0350 · Dr Elizabeth Earland The report cites inadequate record keeping related to risk assessments and observation levels, a lack of training records for staff on risk …	South West Exeter & Great Devon	Devon Partnership NHS Trust	1/1
14 Jul 2014	Adam Williams 2014-0324 · Andrew Haigh Concerns raised regarding the need for improved emergency communication training for nursing staff and a more robust dynamic assessment process for prisoner …	West Midlands Staffordshire (South)	HMP Featherstone	1/1
14 Jul 2014	Shayla Walmsley 2014-0323 · R Brittain Delays in obtaining medical device data from manufacturers, inconsistent distribution of safety notices, and a lack of post-mortem analysis of medical devices …	London London Inner (North)	Department of Health and Social … Medicines and Healthcare Products Regulatory … Medtronic Royal College of Pathologists	0/4
11 Jul 2014	Stuart Long 2014-0320 · Elizabeth Carlyon Confusion regarding appropriate responses to anti-social behavior in intoxicated, mentally unwell individuals led to a failure to take Mr. Long to a …	South West Cornwall	Cornwall Council	0/1
11 Jul 2014	Maria Lopes 2014-0325 · Karen Henderson The report identifies multiple concerns, including consultant urologist on-call arrangements, supervision of out-of-hours urology trainees, recognition and treatment of sepsis, and the …	South East Surrey	Association of Anaesthetists of Great … Basingstoke General Hospital Frimley Park Hospital NHS Trust Intensive Care Society	1/7
9 Jul 2014	Thomas Smith 2014-0316 · Christopher Woolley Critical issues include incomplete handovers, slow response times for children, lack of ambulance transfer, outdated national guidance on pre-hospital antibiotics for meningitis, …	Wales Cardiff & the Vale of Glamorgan	Cwm Taf Health Board National Institute for Health and … Prince Charles Hospital	0/3
9 Jul 2014	Michael Harrison 2014-0317 · Andrew Walker Inadequate measures to treat ice in the car park created an unsafe environment.	London London (North)	Pinner and District Community Association	0/1
9 Jun 2014	Audrey Daws 2014-0318 · Andrew Cox Initial medical assessment failed to order a chest X-ray despite tender abdomen and potential cardiac symptoms, indicating an incomplete diagnostic approach for …	South West Plymouth, Torbay & South Devon	Plymouth Hospitals NHS Trust	0/1
9 Jul 2014	Andrew Hooper 2014-0319 · Lydia Brown Unsecured, high-dose medication was prescribed to an individual unaware of its dangers, raising concerns about safe prescribing practices for those unable to …	South West Exeter & Greater Devon	Devon Clinical Commissioning Group Drug and Alcohol Team Devon	0/2
9 Jul 2014	David Giles 2014-0321 · Zafar Siddique The coroner raises concerns about the unrestricted availability of helium gas canisters, their standard size and lack of modified control valves, and …	West Midlands Birmingham & Solihull	Home Office	1/1
9 Jul 2014	Georgina Taylor 2014-0328 · Simon Nelson Outdated design standards meant that developing soft estate, specifically trees within 4.5m of the carriageway, lacked required vehicle restraint protection or removal, …	North West Manchester (North)	Department for Transport Highways Agency	0/2