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 296 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
8 Jul 2014	Muriel Naylor 2014-0329 · Simon Nelson Despite priority seating, the lack of a mandatory screen barrier in front of the seat in the Alexander Dennis Enviro 400 bus …	North West Manchester (North)	Backhouse Jones Department for Transport Fentons Vehicle and Operator Services Agency	1/4
8 Jul 2014	Anthony Ponting 2014-0332-wp24375 · Michael Rose Concerns relate to a reduced sighting line due to trackside vegetation, incorrect positioning of SHI boards, and tripping hazards on the pedestrian …	South West Somerset (West)	Network Rail	1/1
8 Jul 2014	Thomas Dixon 2014-0315 · Derek Winter The report identifies failures to schedule timely appointments and a missing referral form. The coroner expressed concern that these issues may impact …	North East Sunderland	City Hospitals Sunderland NHS Foundation …	0/1
7 Jul 2014	Harold de Mello 2014-0449 · Gail Elliman A lack of good practice guidelines led to incomplete and inaccurate assessments by First Response Officers, who failed to reconcile conflicting information, …	London London Inner (North)	Tower Hamlets Social Services	1/1
4 Jul 2014	Stanley Bere 2014-0339 · Penelope Schofield Poorly maintained Cardex and incident reporting systems, with unrecorded information and lack of cross-referencing, directly led to injuries not being promptly identified …	South East West Sussex	Salvation Army Villa Adastra Care Home	1/2
3 Jul 2014	Helena Farrell 2014-0309 · Ian Smith The report identifies an inadequate referral system and staffing levels at CAMHS, a failure to recognise the escalation of incidents, unrealistic expectations …	North West Cumbria (South & East)	Cumbria County Council Cumbria Partnership NHS Foundation Trust	2/2
2 Jul 2014	Albert Flynn 2014-0308 · John Pollard Care staff lacked adequate training to assess a deteriorating patient or administer prescribed medication, leading to a significant delay in treatment and …	North West Manchester (South)	HC-One	1/1
2 Jul 2014	Ronald Perry 2014-0302 · John Gittins Inconsistent criteria for requesting CT scans based on time of day or weekend leads to varying levels of care and risks missed …	Wales North Wales (East & Central)	Betsi Cadwaladr University Health Board	1/1
2 Jul 2014	Esther Jones 2014-0296 · John Gittins Significant delays in completing Serious Incident Reviews (SIRs) and disseminating lessons learned prevent timely improvements and risk further patient harm.	Wales North Wales (East & Central)	Betsi Cadwaladr University Health Board	0/1
2 Jul 2014	Gary Daltry 2014-0295 · John Gittins An unmitigated tripping hazard poses a significant risk of falls and potential future deaths if not addressed.	Wales North Wales (East & Central)	Denbighshire County Council	1/1
2 Jul 2014	Henry Marsh 2014-0306 · Andrew Walker The Home Treatment Team was overloaded with excessive patient caseloads, hindering effective multi-disciplinary meetings and compromising patient care.	London London (North)	Department of Health and Social …	1/1
2 Jul 2014	Hywel Hughes 2014-0311 · Karon Monaghan Police training on positional asphyxia is inadequate, and vehicle designs hinder monitoring detainees. The SIA also fails to review restraint-related deaths by …	Wales North West Wales	Home Office North Wales Constabulary Security Industry Authority	1/3
2 Jul 2014	Beryl Brinkman 2014-0314 · Lisa Hashmi Poorly located parking near a junction severely reduces driver visibility, creating a serious risk of harm or death for road users and …	North West Manchester (North)	Rochdale Metropolitan Borough Council	1/1
2 Jul 2014	Farres Ikken 2014-0310 · Andrew Walker Hospital staff lacked the authority to refer patients directly to community psychology services upon discharge, creating a gap in post-hospital care.	London London (North)	Department of Health and Social …	0/1
2 Jul 2014	Liam Hardy 2014-0307 · Selena Lynch The electronic patient record system (RiO) failed to summarise critical patient history, preventing a comprehensive assessment and potentially altering care decisions.	London London (South)	South West London and St …	0/1
1 Jul 2014	John Adams 2014-0293 · Veronica Hamilton-Deeley VERONICA HAMILTON-DEELEY, LLB.	South East Brighton & Hove	Brighton and Sussex University Hospitals National Patient Safety Agency National Research Ethics Service	0/3
1 Jul 2014	Sindy Woodhall 2014-0292 · Lisa Hashmi A lack of regulation prevented intervention when retailers sold toxic gases to a known addict, highlighting a gap in the law and …	North West Manchester (North)	Department for Business Innovation and … Oldham Metropolitan Borough Council Public Health England Trading Standards Institute	4/4
30 Jun 2014	Jake Hardy 2014-0305 · Alison Hewitt Vulnerable young persons with complex needs face increased self-harm and suicide risks in Youth Offender Institutions due to staff lacking adequate training …	North West Manchester (West)	HM Youth Offenders Institute Hindley Ministry of Justice National Offenders Management Service Youth Justice Board	0/4
30 Jun 2014	Jessica Bond 2014-0297 · Caroline Beasley-Murray Propess was inappropriately administered to a patient with a prior caesarean section, despite the known risk of uterine rupture and associated complications.	East of England Essex	Southend University Hospital	0/1
30 Jun 2014	Ian Reid 2014-0288 · David Llewelyn Hospitals could not provide details of existing hip implants, causing unnecessary delays in corrective surgery while implant specifications were sought, which increased …	North West Cumbria (North & West)	Department of Health and Social …	1/1