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 299 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
9 Jun 2014	Ryan Boyle 2014-0263 · Simon Wickens Police force control lacked adequate training for pursuit operators, an efficient notification system for pursuits, and sufficient staffing on the 'Force desk' …	South East Surrey	Surrey Police	1/1
2 Jun 2014	Denise Prior 2014-0262 · Michael Kendall Inadequate hospital record-keeping for oxygen levels, prescription, and the application of the NEWS system poses a risk of future deaths.	South East West Sussex	Western Sussex Hospitals NHS Trust	1/1
2 Jun 2014	Essa Shah 2014-0250 · Tom Osborne Crucial literature on the dangers of co-sleeping is only available in English, preventing non-English speaking mothers from accessing vital safety information.	East of England Bedfordshire & Luton	Luton and Dunstable University Hospital	1/1
2 Jun 2014	Aimee Varney 2014-0249 · Tom Osborne NICE Guidelines for referring patients with suspected epilepsy to a Specialist Tertiary Centre were not followed, risking delayed or inappropriate specialized care.	East of England Bedfordshire & Luton	Luton and Dunstable University Hospital	1/1
30 May 2014	Matthew Purser 2014-0568 · Philip Rogers A prison doctor lacked ACCT training, ACCT trigger event documentation was subjective and lacked detail for accurate assessment, and procedures for obtaining …	Wales Swansea & Neath Port Talbot	HMP Swansea MINISTRY OF JUSTICE National Offender Management Service	0/3
30 May 2014	Richard Jaeger-Forzard 2014-0246 · Richard Hulett The inquest identified unresolved professional disagreements regarding the proper steps needed to prevent similar occurrences, which could not be adjudicated.	South East Buckinghamshire	Terex Global Gmbh	1/1
29 May 2014	Stephen Ward 2014-0248 · ME Hassell The mental health crisis team lacked a clear protocol for following up with police after requesting a welfare check, leading to delays …	London London Inner (North)	Camden & Islington NHS Foundation …	1/1
29 May 2014	Magdalen Dwerryhouse 2014-0244 · Alan Walsh Poor communication led to a missed patient appointment. A health trust also failed to engage with the fire service, preventing vulnerable individuals …	North West Manchester (West)	5 Boroughs Partnership NHS Foundation …	1/1
29 May 2014	Loui Aspinall 2014-0243 · Alan Walsh Tour operator safety audits falsely indicated trained lifeguards and rescue equipment, with the lifeguard lacking child resuscitation skills, highlighting a critical gap …	North West Manchester (West)	Federation of British Tour Operators	0/1
29 May 2014	Dana Baker 2014-0242 · Geraint Williams Inadequate inter-agency communication and a lack of shared knowledge, exacerbated by confidential Individual Management Reviews, prevented a comprehensive understanding of mutual concerns.	West Midlands Worcestershire	Worcestershire Safeguarding Children’s Board	1/1
29 May 2014	Mark Duggan 2014-0182 · HHJ Keith Cutler CBE Insufficient intelligence gathering and a failure to exhaust all intelligence avenues regarding key individuals prior to the stop, impacting subsequent police actions.	London London (North)	Association of Chief Police Officers Coroner's Society Crown Prosecution Service Home Office	5/7
28 May 2014	Laura Page 2014-0254 · Lydia Brown Inadequate clinician response to failed home visits included lack of client contact and failure to escalate issues. Policies for escalation, welfare checks, …	East Midlands Leicester City & South Leicestershire	Leicester Partnership NHS Trust	1/1
28 May 2014	Arnold Soulsby 2014-0241 · Robin Balmain Current regulations do not mandate retrospective fitting of forward mirrors on lorries, leaving many vehicles without a crucial safety feature and increasing …	West Midlands Black Country	Department for Transport	1/1
27 May 2014	Gerardo Tonogbanua 2014-0245 · Maria Voisin A rescue boat's fall wire failed due to an overstressing winch, highlighting a lack of 'system' design consideration in regulations. An electronic …	South West Avon	British Standards Institution Department for Transport Maritime and Coastguard Agency	0/3
25 May 2014	Michaela Christoforou 2014-0285 · Andrew Walker All staff at the unit did not carry ligature cutters, posing a significant risk in preventing self-harm incidents.	London London (North)	Care UK	1/1
25 May 2014	Liam Coleman 2014-0312 · Andrew Walker There was an insufficient number of ambulances available to adequately cover urgent Red 1 and Red 2 calls, indicating a critical resource …	London London (North)	Department of Health and Social …	0/1
23 May 2014	Komba Kpakiwa 2014-0301 · Caroline Beasley-Murray The pool had an inherently dangerous profile with inadequate risk assessments, no lifeguards, ineffective supervision (unmonitored CCTV), unclear signage, and untrained staff …	East of England Essex	Chartered Institute of Environmental Health Institute of Occupational Safety and …	1/2
23 May 2014	Josephine Foday 2014-0301-wp24614 · Caroline Beasley-Murray The pool's inherently dangerous profile was not properly risk-assessed. A lack of lifeguards, unmonitored CCTV, unclear signage, and untrained staff in aquatic …	East of England Essex	Chartered Institute of Environmental Health …	1/1
23 May 2014	Ross Boyd 2014-0313 · Tom Osborne An inadequate assessment of the deceased's needs resulted in an inappropriate placement at a care home, failing to meet his specific requirements.	South East Milton Keynes	No addressees parsed	1/0
23 May 2014	Christian Devereux 2014-0240 · Robert Chapman A HANS type device likely would have prevented or reduced fatal head and neck injuries in a collision. Many drivers in the …	East Midlands Rutland & North Leicestershire	RAC Motorsports Association	1/1