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 297 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
30 Jun 2014	Dayani Chauhan-Ahmed 2014-0287 · Lydia Brown Ineffective communication systems and unclear escalation policies hindered timely intervention during labor, compounded by insufficient staff availability during periods of high demand.	East Midlands Leicester City & South Leicestershire	University Hospitals of Leicester NHS …	1/1
28 Jun 2014	Ahmad Khan 2014-0291 · Donald Coutts-Wood Easy access to a low perimeter wall, facilitated by a nearby barrier, creates a dangerous fall hazard for individuals, including children.	Yorkshire and the Humber South Yorkshire (West)	Q-Park Limited Sheffield City Council (Planning) Sheffield County Council	1/3
27 Jun 2014	Ashley Ponsonby 2014-0386-wp24600 · Nigel Meadows Poor communication by a locum SHO regarding observation plans and failure to suggest Naloxone for drug overdose led to inappropriate management and …	North West Manchester City	Secretary of State for Health	1/1
26 Jun 2014	Sadik Miah 2014-0290 · Andrew Harris Inadequate physical health monitoring for psychiatric inpatients, including inconsistent ECG review for antipsychotic risks and significant delays for urgent non-emergency medical opinions, …	London London (Inner South)	South London and Maudsley NHS …	0/1
25 Jun 2014	Marion Turner 2014-0300 · Caroline Beasley-Murray The report identifies that a message left for the deceased's CPN regarding concerns about her mental health was not read until after …	East of England Essex	North Essex Partnership NHS Foundation …	0/1
25 Jun 2014	Peter Hinchliffe 2014-0284 · Raymond Curtis Significant delays in diagnostic investigations across both private and NHS sectors, coupled with inconsistent advice and management for young athletes experiencing syncope, …	Yorkshire and the Humber South Yorkshire (East)	BMI Hospital Thornbury Department of Health and Social … NHS England Sheffield Teaching Hospitals NHS Foundation …	0/4
25 Jun 2014	Wilfred Aspinwall 2014-0283 · Andre Rebello Healthcare provider at HMP Liverpool did not receive critical PPO and Clinical Review reports, hindering effective implementation of recommendations for prison fatalities.	North West Liverpool	Prison and Probation Ombudsman	0/1
25 Jun 2014	Ralph Goslin 2014-0282 · ME Hassell An incorrectly presented reference range for sodium valproate levels led a junior doctor to misinterpret a sub-therapeutic result, delaying the recognition of …	London London Inner (North)	University College London Hospitals NHS …	1/1
25 Jun 2014	Lloyd Butler 2014-0281 · Louise Hunt A pervasive lack of professionalism, leadership, and appropriate training in the custody suite led to an unacceptable culture and inadequate control over …	West Midlands Birmingham & Solihull	West Midlands Police	1/1
23 Jun 2014	Joan Richardson 2014-0276 · David Hinchliff The GP practice failed to provide emergency care during training closure, delaying assessment of an obviously unwell patient by 24 hours, which …	Yorkshire and the Humber West Yorkshire (East)	Fountain Medical Centre Leeds West Clinical Commissioning Group	1/2
20 Jun 2014	Samuel Openshaw 2014-0280 · Peter Dean Slow electronic transfer of echocardiograph studies to specialist centers and high workload of paediatric retrieval teams pose significant risks for urgent child …	East of England Suffolk	Congenital Heart Services Clinical Reference … Coronary Heart Disease Review Coronary Heart Disease Review’s Clinical … East Anglia Team	0/4
20 Jun 2014	Redmond Johnson 2014-0279 · Peter Dean Prison healthcare lacked robust processes for gathering detainee medical history, conducting medication reviews, documenting test results, and assessing fitness for transfer, risking …	East of England Suffolk	Ministry of Justice NHS England	0/2
20 Jun 2014	Else Harvey-Samuel 2014-0278 · Peter Dean Doctors failed to provide adequate clinical information for imaging requests, and post-incident investigations lacked robustness to identify lessons learned effectively.	East of England Suffolk	West Suffolk Hospital	0/1
20 Jun 2014	Peter Farebrother 2014-0274 · John Ellery Failures in patient transfer, handover of observation status, and returning a ligature risk item (belt) led to an unsafe environment. The effectiveness …	West Midlands Shropshire, Telford & Wrekin	South Stafford and Shropshire Healthcare …	0/1
19 Jun 2014	Shaun Maslin 2014-0277 · Richard Travers There are no specific qualifications for pressure testing gas pipelines and a lack of national requirements for regular retraining and re-testing of …	South East Surrey	Department of Business, Innovations and … Energy and Utilities Skills	1/2
17 Jun 2014	Sol Hadhasseh 2014-0272 · David Osborne A mental health Trust's reliance on a delayed GP referral, rather than a direct Trust-to-Trust transfer, for a patient with complex needs …	East of England Norfolk	Coventry and Warwickshire Partnership NHS …	0/1
17 Jun 2014	Audrey Garland 2014-0271 · John Pollard Failures by GP and District Nursing services to recognize and appropriately treat severe ulcers, combined with a lack of arranged hospital transport, …	North West Manchester (South)	Blackpool Teaching Hospitals NHS Foundation … North Shore Surgery	1/2
16 Jun 2014	Mrs Care 2014-0273 · Andrew Cox Unexplained extensive bruising, likely caused during hospital care and potentially related to hoist use, contributed to the deceased's death, with no clear …	South West Cornwall	Royal Cornwall Hospital Truro	0/1
16 Jun 2014	David O’Garro 2014-0270 · ME Hassell The report cites that a nurse did not complete a cell sharing risk assessment and staff lacked clarity and shared understanding regarding …	London London Inner (North)	HMP Pentonville	0/1
13 Jun 2014	Alun Sheppard 2014-0268 · John Gittins The Health Board struggles to balance patient confidentiality with the crucial need for familial support to optimize recovery, potentially hindering patient well-being.	Wales North Wales (East & Central)	Betsi Cadwaladr University Health Board	1/1