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 298 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
11 Jun 2014	June Rose 2014-0267 · Lorna Tagliavini A lack of training on the correct dosage and morphine equivalent of fentanyl patches led to an erroneous prescription, contributing to the …	London London (West)	Royal College of General Practitioners	0/1
11 Jun 2014	Bridget Cahill 2014-0266 · Robin Balmain The coroner questions how a patient prescribed morphine can overdose despite receiving less than the prescribed amount, suggesting attention be given to …	West Midlands Black Country	National Institute for Health and …	1/1
10 Jun 2014	Lucy Moffatt 2014-0261 · Christopher Dorries Window restraints were found to be misleadingly insecure, easily defeated, and establishments lacked proper key restriction, further compounded by CQC inspectors' unawareness …	Yorkshire and the Humber South Yorkshire (West)	Care Quality Commission Department of Health and Social …	2/2
9 Jun 2014	John Cook 2014-0578 · Nicholas Gardiner Inadequate design and management of DNA CPR forms, including unclear validity wording and lack of clear hospital identification, caused significant confusion and …	South East Oxfordshire	NHS England	1/1
9 Jun 2014	Bradley Cockel 2014-0298 · Eleanor McGann The drug involved, and several of its chemical compounds, were not fully controlled by legislation, leading to regulatory gaps and potential public …	East of England Essex	The Advisory Council on the …	0/1
19 Jun 2014	M5 (Seven) 2014-0654 · Michael Rose A firework display adjacent to the M5 caused greatly reduced visibility and a fatal multi-vehicle collision, highlighting a lack of preventative measures …	South West Somerset (West)	Department for Transport Directorate for Business Innovation and … Directorate South West Health and Safety Executive	0/5
9 Jun 2014	Daniel McCallum Keane 2014-0260 · Kevin McLoughin The GP's inadequate record-keeping and inaction, despite being alerted to an "extremely worrying" and high-risk situation for a diabetic patient, critically failed …	North West Manchester (West)	Department of Health and Social …	1/1
9 Jun 2014	William Beckwith 2014-0258 · Robert Hunter A frail, elderly patient with a history of falls was discharged home in the early morning without formal assessment of his or …	East Midlands Derby & Derbyshire	Chesterfield Royal Hospital	1/1
9 Jun 2014	Charles Hardiman 2014-0257 · Clare Bailey An open front door created a wind tunnel, causing the back door of a public house to move forcibly and suddenly, leading …	North East Teesside	Stockton Public House	0/1
8 Jun 2014	James McArdle 2014-0264 · Alan Wilson The withdrawal of a coloured wristband system for falls risk without replacement removed a vital protection, increasing the risk of falls for …	North West Wirral	Arrow Park Hospital NHS Trust	1/1
6 Jun 2014	Frances Bell 2014-0299 · Caroline Beasley-Murray The investigation lacked a Root Cause Analysis and senior clinical input, coupled with unacceptable delays in patient transfer to theatre for critical …	East of England Essex	Southend Hospital	0/1
6 Jun 2014	Katie Davies 2014-0255 · Alan Walsh Undetected "blind spots" in the hospital bleeper system hampered emergency response, and inadequate protocols for transferring Cerebral Venous Sinus Thrombosis patients to …	North West Manchester (West)	Department of Health and Social …	1/1
6 Jun 2014	James Boylan 2014-0253 · Ian Smith Unidentified ligature points, inadequate patient searching for contraband, poor communication of escalating risks, and incomplete GRIST assessments contributed to the patient's death …	North West Cumbria (South & East)	Care Quality Commission Cumbria Clinical Commissioning Group Cumbria Partnerships NHS Foundation Trust Department of Health and Social …	1/5
5 Jun 2014	Archie Hames 2014-0259 · Martin Fleming The combined use of a specific tracheostomy tube and a particular Velcro strap attachment compromised the tube's integrity, likely causing detachment and …	South East Surrey	Department of Health and Social … Surrey Community Health	1/2
5 Jun 2014	Sophie Allen 2014-0256 · Derek Winter Looped blind cords continue to pose a serious strangulation risk to young children, with existing installations in homes lacking the improved safety …	North East Sunderland	Department for Business Innovation and …	1/1
5 Jun 2014	Thomas Maher 2014-0252 · John Pollard Missing medical records, unupdated risk assessments, non-functioning falls alarms, systemic delays in patient transfers, and incompatible paper/electronic record systems severely hampered patient …	North West Manchester (South)	Central Manchester University Hospitals NHS …	1/1
4 Jun 2014	John Day 2014-0251 · Caroline Sumeray Out-of-hours doctors lack crucial access to patient medical records, particularly allergy information, increasing the risk of incorrect medication prescriptions when patients provide …	South East Isle of Wight	Beacon Healthcare Isle of Wight Clinical Commissioning …	2/2
3 Jun 2014	Dean Hutchinson 2014-0556 · David Ridley The wording in the modification to the Fire Diary gives equal weighting to options when the evidence supports a preference for reviews …	South West Wiltshire and Swindon	Ministry of Defence	1/1
3 Jun 2014	Robert Wood 2014-0556-wp26758 · David Ridley Fire risk assessment guidelines did not prioritise pre-alteration reviews, and Junior Fire NCOs lacked specific training on complex electrical overload risks, including …	South West Wiltshire and Swindon	Ministry of Defence	1/1
2 Jun 2014	Jennifer Morrison 2014-0265 · Alan Wilson Missing medical records hampered investigations, and bed shortages combined with inadequate staffing during peak holiday seasons led to prolonged assessment unit stays …	North West Wirral	Arrowe Park Hospital	1/1