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 302 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
30 Apr 2014	Sukbir Singh Rana & Mandip Singh 2014-0191 · Robin Balmain The appropriateness of a 60 MPH speed limit on a bending country lane with limited lighting is questioned, as the maximum theoretical …	West Midlands Black Country	Sandwell Metropolitan Borough Council	0/1
29 Apr 2014	Joanne Oliver 2014-0210 · Robert Chapman A severe lack of national guidance for critical patient transfer decisions results in insufficient risk assessment protocols covering patient fitness, staff seniority, …	North West Manchester City	The Faculty of Intensive Care … Intensive Care Society	0/2
29 Apr 2014	Dafydd Watts 2014-0194 · T G Moore Drug literature and the British National Formulary fail to adequately inform physicians about rare but potential fatal occurrences associated with medication.	South West Avon	British National Formulary UCB Pharma	0/2
29 Apr 2014	Stephen Widman 2014-0189 · Ian Arrow The provided text does not detail any specific concerns.	South West Plymouth, Torbay & South Devon	Department of Health and Social … Torbay Hospital	0/2
28 Apr 2014	Robert Perkins 2014-0195 · Peter Harrowing The coroner noted a failure to immobilise the patient's neck with a cervical collar, despite neurosurgeon's instructions, and that medical staff did …	South West Avon	North Bristol NHS Trust	1/1
28 Apr 2014	Yasmin Richards 2014-0193 · Peter Harrowing The A46 "Hartley Bends" has an inappropriate speed limit and inadequate road signage, markings, and warning features, contributing to a high risk …	South West Avon	Highways Agency	1/1
28 Apr 2014	Jennifer Tompkins 2014-0188 · Philip Barlow The coroner expressed concern about potential training issues related to the administration of IV medications, and that the stopping of IV vancomycin …	London London (Inner South)	Kings College Hospital NHS Foundation …	0/1
24 Apr 2014	Stephen Goodhall 2014-0184 · John Pollard A lack of clear policy for determining ITU candidacy and contradictory messages from nursing and medical staff pose risks to patient care.	North West Manchester (South)	University Hospital of South Manchester …	0/1
22 Apr 2014	Rosemary Oladejo 2014-0203 · Chinyere Inyama A critical lack of communication between the GP and responsible clinician led to unauthorized and unrecorded changes in the patient's medication, including …	London London (West)	Central and North West London … NHS Hillingdon Clinical Commissioning Group	2/2
22 Apr 2014	Andrey Wakefield 2014-0186 · Andrew Haigh Poor communication of patient discharge information to GPs, especially for practices distant from the hospital, poses a significant risk to ongoing patient …	West Midlands Staffordshire (South)	University Hospital of North Staffordshire …	1/1
22 Apr 2014	Michael Worrall 2014-0179 · R Brittain The limited availability of psychological therapy at Avesbury House risks adverse outcomes for patients, particularly upon discharge to the community if prior …	London London Inner (North)	Barnet Enfield and Haringey Mental …	0/1
17 Apr 2014	Karen Peters 2014-0178 · Andrew Cox No specific concerns were detailed in the provided text, beyond broad categories of 'Nursing and Medical' matters.	Plymouth, Torbay & South Devon	Royal Cornwall Hospitals NHS Trust	0/1
17 Apr 2014	Paul Millis 2014-0176 · Donald Coutts-Wood The highway design features a very short and acutely angled lane merger near a junction, creating significant line-of-sight obstructions and danger for …	East Midlands Leicester City & South Leicestershire	Leicester City Council	1/1
17 Apr 2014	Muriel Dawson 2014-0173 · Timothy Ratcliffe The bus design lacked restraints for seated passengers, especially in the aisle seat, leading to fatal injury during a sudden stop. Type-approval …	Yorkshire and the Humber West Yorkshire (West)	Optare Transport Research Laboratory Vehicle Operator Services Agency	1/3
16 Apr 2014	Sari Keen 2014-0180 · Tom Osborne Insufficient staffing levels overwhelmed healthcare professionals, and a lack of awareness among staff regarding 'un-recordable blood pressure' as a medical emergency led …	East of England Bedfordshire & Luton	Luton and Dunstable University Hospital	1/1
16 Apr 2014	Kathryn Sawyer 2014-0177 · Jacqueline Lake A failure to adequately review and plan a reduction of high-dose addiction medications occurred, alongside a lack of detailed record-keeping regarding medication …	East of England Norfolk	Roundwell Medical Centre	1/1
15 Apr 2014	Kevin Scarlett 2014-0174 · Tom Osborne The prison service and healthcare failed to assess the deceased's suicide risk, as staff lacked access to proper risk assessment tools or …	South East Milton Keynes	National Offender Management Service	1/1
15 Apr 2014	Philip Dean 2014-0172 · Fiona Wilcox Mental health services were underfunded and under-resourced, leading to fragmented care, inadequate recording of critical information, and delayed professional assessments for severely …	London London (Inner West)	Clinical Commissioning Group for Wandsworth South Wet London and St …	1/2
15 Apr 2014	Desiree Falvo 2014-0171 · Fiona Wilcox A&E departments lack sufficient clinicians skilled in emergency surgical tracheotomy, indicating inadequate training and cover for critical airway management procedures.	London London Inner (West)	NHS England	1/1
14 Apr 2014	Francis Golding 2014-0136 · ME Hassell The junction design poses significant and repeatedly fatal risks to cyclists due to collisions with left-turning vehicles and inadequate space, with slow …	London London Inner (North)	Camden Council	1/1