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 300 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
23 May 2014	Samarjit Singh 2014-0239 · Andre Rebello The lack of a Specialist Community Perinatal Mental Health Service and a Mother and Baby in-patient unit in the region resulted in …	North West Wirral	Department of Health and Social … NHS England Wirral Clinical Commissioning Group	2/3
23 May 2014	Clive Clinton 2014-0238 · John Gittins A care home's complaints procedure failed, preventing family concerns about poor care (e.g., hygiene, medication) from reaching senior management and placing residents …	Wales North Wales (East & Central)	European Care	0/1
22 May 2014	Simon Haines 2014-0236 · David Osborne There was no clear protocol for signposting individuals struggling to accept decisions or outcomes, and little consideration was given to re-signposting to …	East of England Norfolk	Norfolk County Council	0/1
21 May 2014	Mark Bartholomew 2014-0237 · Simon Nelson Inadequate emergency response included missing patient details and lost documentation. Critical delays occurred because ligature cutters were not readily available and observation …	North West Manchester (North)	Broudie Jackson Canter DAC Beachcroft Department of Health and Social … Greater Manchester West Mental Health …	0/4
20 May 2014	Rainer Wickens 2014-0234 · Richard Travers Significant delays in clot treatment and CTPA scans were caused by poor communication during handovers and between medical staff. Additionally, medical notes …	South East Surrey	St George’s Healthcare NHS Trust	1/1
19 May 2014	Denise Parramore 2014-0247 · Donald Coutts-Wood A lack of open, two-way communication and inability to access shared documentation between primary and secondary care meant psychiatric services were unaware …	Yorkshire and the Humber South Yorkshire (West)	NHS England NHS Sheffield Clinical Commissioning Group	0/2
19 May 2014	Peter Franklin 2014-0230 · Patricia Harding Confusion in terminology and lack of information sharing between health teams and the CRISIS team hindered effective care. Significant delays in documentation …	South East Mid Kent & Medway	Kent and Medway NHS and … Maidstone and Tunbridge Wells NHS …	2/2
19 May 2014	Gregg O’Reilly 2014-0221 · ME Hassell The coroner noted a missed opportunity to refer the deceased to critical care, and the lack of observation records during a critical …	London London Inner (North)	Barts Health	1/1
19 May 2014	Stephen Owens 2014-0222 · Graeme Hughes The report identifies that a street lamp was unilluminated and another was obscured by foliage, which likely affected the driver's ability to …	Wales Powys, Bridgend & Glamorgan Valleys	Rhondda Cynon Taf County Borough …	0/1
12 May 2014	Harold Henshall 2014-0217 · David James Inadequate street lighting and crossing facilities on Church Street, especially near St Edwards Church, increased the risk to elderly pedestrians crossing the …	West Midlands Stoke-on-Trent & North Staffordshire	Staffordshire County Council	0/1
16 May 2014	William Piercy 2014-0231 · Paul Marks A disengaged seatbelt left a passenger unrestrained, leading to fatal injury; a seat belt alarm would have alerted carers to this safety …	Yorkshire and the Humber Kingston upon Hull & the East …	Royal Society for the Prevention …	0/1
15 May 2014	Gary Bradshaw 2014-0232 · John Pollard The hospital experienced significant delays in diagnosis, inappropriate medication prescribing before test results, inadequate patient monitoring, and poor communication/IT systems, leading to …	North West Manchester (South)	Department of Health and Social … Stockport NHS Foundation Trust	2/2
14 May 2014	Arthur Shaw 2014-0593 · David Horsley The process for renewing driving licenses for individuals over 70 lacks specific assessment of mental fitness, relying only on sight and hearing …	South East Portsmouth and South East Hampshire	Department for Transport	0/1
13 May 2014	Mitchell Clifton 2014-0227 · Andrew Haigh The wide access way to a car park, shared by pedestrians and vehicles, has a potentially unsafe layout that could be improved …	West Midlands Staffordshire South	Casualty Reduction Team	2/1
12 May 2014	Amanda Richards 2014-0228 · S McGovern The absence of domestic sprinkler systems in special accommodation, like Ms Richards', significantly increased the risk of death from fire.	West Midlands Coventry	Whitefriars Housing	1/1
12 May 2014	Keiran Toman 2014-0225 · Fiona Wilcox Psychiatric services failed to adequately assess patient capacity to refuse family contact, leading to isolation and increased risk of deterioration, especially when …	London London Inner (West)	Hafod Community Mental Health Team NHS England Windsor and Maidenhead Community Mental … Wokingham Community Mental Health Team	0/4
12 May 2014	Courtney Mills 2014-0224 · David Horsley Repeated prescription errors and severe communication breakdowns between the GP surgery and hospital led to dangerous delays in obtaining critical medication, putting …	South East Portsmouth & South East Hampshire	Portsmouth Hospitals NHS Trust Waterside Medical Centre	2/2
12 May 2014	Terence Fernandes 2014-0220 · Tom Osborne Lack of basic first aid training among train and station staff prevented the recognition and proper management of a critical medical emergency, …	East of England Bedfordshire & Luton	Association of Train Operating Companies Department for Transport	1/2
9 May 2014	Ann Bennett 2014-0233 · David Hincliff The coroner endorsed findings from a Trust investigation report that identified serious issues contributing to a potentially avoidable death, necessitating a robust …	Yorkshire and the Humber West Yorkshire (East)	Leeds Teaching Hospitals NHS Trust	0/1
9 May 2014	Linda Fisher 2014-0226 · Alan Wilson Inaccurate medication dosages resulted from doctors relying on patient-reported weight, and critical family medical history was not obtained or effectively communicated among …	North West Blackpool & Fylde	Blackpool Teaching Hospitals NHS Foundation …	1/1