Stephen Amer
AI-generated concerns summaryThe provided document is truncated, and the specific concerns raised by the coroner to prevent future deaths are not present in the available text.
Addressed to: Hertfordshire County Council
Source · Prevention of Future Deaths
Prevention of Future Deaths Reports
Browse 6,493 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.
Reports
Nathan Healer
AI-generated concerns summaryThe coroner raised concerns regarding the delay in finalising new NICE guidance on diabetes in pregnancy, specifically whether it can be expedited. There was also a recommendation to revisit existing guidance if new recommendations are not forthcoming.
Addressed to: Department of Health and Social Care
Charles Lawrence
AI-generated concerns summaryAlexandra Rose Care Home does not have a protocol for calling a doctor to examine a resident who experiences more than one fall within a 24-hour period.
Addressed to: Alexandra Rose Care Home
Donna Kirkland
AI-generated concerns summaryThe coroner noted patients had unlimited access to alcohol-based hand sanitising gels and were permitted to decant and keep them in their rooms. There was also a lack of staff awareness regarding the gel's alcohol content and potential for ingestion.
Addressed to: Coventry and Warwickshire Partnership Trust; Department of Health and Social Care
Graham Darby
AI-generated concerns summaryA specific threat made by Mr Darby to take his own life if evicted, mentioning a knife and rope, was not sufficiently flagged by other agencies to his housing provider, Family Mosaic. This meant Family Mosaic was unaware of the direct threat when making decisions.
Addressed to: East London NHS Foundation Trust; Family Mosaic; Hackney Alcohol Recovery Centre
John Thorpe
AI-generated concerns summaryThe coroner noted concerns regarding the deceased's self-referral to mental health services instead of a direct referral, a lack of recorded follow-up, and that the patient's history and British National Formulary advice on anti-depressants were not adequately considered.
Addressed to: East Midlands Local Education and Training Board; Lincolnshire East Clinical Commissioning Group
Kenneth Paul
AI-generated concerns summaryThe delivery vehicle involved in a collision was not fitted with an automatic audible warning device for reversing, and there is no legislative requirement for such devices on light commercial vehicles of this type.
Addressed to: Department for Transport
Graeme Kidd
AI-generated concerns summaryConcerns included locum doctors lacking access to electronic records and awareness of mental health support teams. Additionally, GPs faced delays in referring patients to mental health services due to mandatory physical checks, and medication advice was unavailable.
Addressed to: Norfolk and Suffolk NHS Foundation Trust
Yahya Khan
AI-generated concerns summaryThe coroner noted potential improvements to NICE guidance regarding repeated healthcare visits and considering rare surgical conditions in young children. Concerns were also raised about the lack of a unified electronic patient record system and the need to view prolonged illnesses as a linked process.
Addressed to: National Institute of Health and Care Excellence
Molly Keen
AI-generated concerns summaryThe coroner raised concerns about a lack of clarity in joint antenatal care between two trusts, leading to inconsistent use and recording of customised growth charts and fundal height measurements. This obscured fetal growth assessment and resulted in no referral despite indications of below-normal growth.
Addressed to: West Hertfordshire Hospitals NHS Trust
Edward Devlin
AI-generated concerns summaryThe coroner identified a practice where nurses reportedly slide medication, including controlled drugs, under cell doors rather than directly handing it to patients. This raises concerns about whether patients receive their medication, the accuracy of drug records, and the potential for drug misuse or trading within the establishment.
Addressed to: Care UK; HMP Durham; National Offender Management Service; Tees Esk Wear Valley NHS Foundation Trust
Marcin Stoga
AI-generated concerns summaryThe Prisoner Escort Record containing a previous overdose history was not available during Mr Stoga's initial assessment. Additionally, prisoners with mental health issues are not routinely or thoroughly assessed upon return from court hearings.
Addressed to: HMP Bullingdon
Kathleen Cornthwaite
AI-generated concerns summaryThe drug chart did not specify the precise dose of tramadol dispensed.
Addressed to: East Lancashire Healthcare NHS Trust
Joshua Brown
AI-generated concerns summaryThe coroner noted limited information sharing with Mr. Brown's parents, his primary support, due to his wishes and their non-carer status, which impacted their ability to assist the team. There was also no system for family members to review and confirm the accuracy of notes made by the community team.
Addressed to: Care Quality Commission; Department of Health and Social Care; Kent and Medway NHS and Social Care Partnership Trust
Michael Warren
AI-generated concerns summaryBracknell Forest Council's Highway Inspectors lacked appropriate guidelines and training for identifying tree hazards and employing effective inspection methodology. The coroner also noted limited clear guidance for Local Authorities on highway tree inspection systems.
Addressed to: Bracknell Forest Borough Council; Chartered Institute of Highways and Transportation
Julie Robertson
AI-generated concerns summaryThe absence of a blood fridge on the ward caused a delay in accessing anticipated blood. Additionally, poor record keeping was identified, with staff showing ongoing unawareness of good practice despite some training.
Addressed to: Southend University Hospital
Silvia Taylor
AI-generated concerns summaryUnsuccessful attempts to contact Mrs. Taylor were not acted upon for several hours, and these difficulties were not conveyed to her family. The coroner suggests reviewing 'no speech call procedures' for after-hours support.
Addressed to: Bracknell Forest Council; Harmoni South East; Woking Borough Council
Stephen Church
AI-generated concerns summaryThe British Transport Police experienced a broken chain of command, and staff from the psychiatric liaison service and Royal Berkshire Hospital had insufficient knowledge of interagency protocols. This contributed to a lack of joint working and delays in arranging a Mental Health Act assessment.
Addressed to: Berkshire Healthcare NHS Foundation Trust; British Transport Police; Royal Berkshire NHS Foundation Trust; Thames Valley Police
Ming Cheung
AI-generated concerns summaryThe coroner noted that the location where Miss Cheung crossed the road was an unofficial crossing point used by many pedestrians, with near-misses previously occurring. A large Tesco sign at the crossing obscured the view for both pedestrians and drivers.
Addressed to: Tesco Plc
Elaine Jobe
AI-generated concerns summaryInsufficient record-keeping for risk assessments and observation levels, coupled with a lack of staff training records, was identified. Additionally, communication of patient status to incoming staff and named nurse responsibilities require review.
Addressed to: Devon Partnership NHS Trust