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 301 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
9 May 2014	Gianna Khan 2014-0219 · Tom Osborne The coroner raised concerns that a patient reporting a head injury was streamed to the GP clinic instead of being seen by …	East of England Bedfordshire & Luton	Bedfordshire Clinical Commissioning Group	1/1
9 May 2014	Margaret Connor 2014-0215 · Jacqueline Lake Inadequate procedures for wheelchair checks resulted in faulty equipment, while communication breakdowns led to doctors being misinformed about a patient's injury despite …	East of England Norfolk	Heathers Nursing Home	1/1
9 May 2014	Lisa Webb 2014-0213 · Andrew Harris Sub-optimal asthma management by the GP involved failure to assess asthma history, unrecorded vital signs, lack of objective measurements (peak flow/oximetry), and …	London London (Inner South)	Basildon Road Surgery NHS England	1/2
9 May 2014	Gary Richards 2014-0212 · Andrew Harris Psychiatric services failed to properly assess self-harm risk, communicate patient vulnerabilities, ensure follow-up due to unrecorded contact details, and implement crucial recommendations …	London London (Inner South)	South London and Maudsley Trust	1/1
9 May 2014	Akua Anokye-Boateng 2014-0211 · Andrew Harris The report raises concerns about the use of NSAIDs in children with sickle cell disease, specifically regarding the potential for a single …	London London (Inner South)	Medicines and Healthcare Products Regulatory …	1/1
9 May 2014	Ernest Harper 2014-0223 · Ian Pears Design flaws allowed falling between the safety barrier and vehicle, compounded by the lack of formal assessment for passenger health and mobility …	East of England Bedfordshire & Luton	Bedford Borough Council	1/1
8 May 2014	Frank Pope 2014-0216 · R Brittain There is no clear "back-up" process to ensure follow-up for patients lacking capacity, particularly when family members are not copied into correspondence, …	London London Inner (North)	Northern Medical Centre Whittington Hospital NHS Trust	1/2
8 May 2014	Anthony Lapping 2014-0214 · Karen Dilks Highly flammable insulation material in a Hotpoint fridge freezer caused rapid fire spread, severely reducing escape opportunities and highlighting an urgent need …	North East Newcastle Upon Tyne	Indesit Company	1/1
8 May 2014	Rajesh Parkash 2014-0207 · Richard Travers Failures in staff communication regarding updates and driving guidance, insufficient ongoing driver training, and inadequate supervision requirements for paramedics pose systemic risks.	South East Surrey	Association of Ambulance Chief Executives London Ambulance Service	0/2
8 May 2014	Sopefoluwa Peters 2014-0206 · Andrew Tweddle Hazardous steps, poorly illuminated and without a handrail, combined with a low riverside safety barrier, created a dangerous environment, especially for intoxicated …	North East County Durham & Darlington	Durham County Council	1/1
7 May 2014	Peter Brookes 2014-0205 · R Brittain Concerns include hospital administration of Parkinson's medication not following patient regimens, unavailability of doctors for weekend reviews, and an unresolved dispensing error …	London London Inner (North)	University College London Hospitals NHS …	1/1
7 May 2014	Emma Lifsey 2014-0204 · Heida Connor The coroner noted that old-style filament bulbs in wig wag lights at the Beech Hill crossing were less than half as bright …	East Midlands Nottinghamshire	Network Rail	0/1
9 May 2014	Abiola Dosunmu 2014-0209 · Andrew Walker Critical test results were not communicated effectively between departments, to the patient, or to the GP, resulting in a missed diagnosis and …	London London (Inner South)	Kings College Hospital NHS Foundation …	1/1
5 May 2014	Donald Spooner 2014-0208 · Karen Henderson The absence of a compulsory protective helmet requirement for motorised bicycles traveling over 15 MPH significantly increases the risk of severe, unsurvivable …	South East West Sussex	Department for Transport Royal Society for the Prevention …	1/2
1 May 2014	Darren Arnoup 2014-0199 · David Osborne Concerns exist regarding the coordination and handover of care for a patient with known mental health issues and suicidal ideation following discharge …	East of England Norfolk	Mundesley Medical Centre NHS North Norfolk Clinical Commissioning …	1/2
1 May 2014	Elizabeth Cooper 2014-0197 · Philip Sharp No specific safety concerns were detailed in the report text, only a general statutory duty to report matters of concern.	North West Cumbria (South & East)	General Medical Council National Institute for Health and … The Chief Coroner	0/3
1 May 2014	Sidney Martin 2014-0196 · Robert Turnbull The dangerous condition of canal bridge steps and poor lighting in the area pose a significant risk to public safety.	Yorkshire and the Humber North Yorkshire (West)	North West Waterways Canal & … The Chief Coroner	1/2
30 Apr 2014	Samiyo Farah 2014-0202 · Lisa Hashmi Critical concerns include the absence of national observation guidelines for children in mental health units, poor communication protocols for inter-sector patient transfers, …	North West Manchester (North)	Affinity Healthcare Ltd Central Manchester University Hospitals NHS … Department of Health and Social … Greater Manchester West Mental Health …	1/6
30 Apr 2014	Beryl French 2014-0198 · Stephanie Haskey Nursing staff lacked understanding of DNACPR forms and End-of-Life Care planning was insufficient, risking patients not receiving appropriate dignified care in future …	East Midlands Nottinghamshire	Lifestyle Care PLC	1/1
30 Apr 2014	Mary Wanya 2014-0192 · David Hinchliff Significant delays in urgent psychiatric assessments, an inadequate system for mentally ill patients in medical units, and a flawed investigation report by …	Yorkshire and the Humber West Yorkshire (East)	Leeds Teaching Hospitals NHS Trust	0/1