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 303 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
14 Apr 2014	Paul Ashton 2014-0170 · Alan Walsh There was a lack of consultation with the cardiac transplant team and no established protocol for managing heart transplant patients undergoing non-cardiac …	North West Manchester (West)	Department of Health and Social … Medicines and Healthcare Products Regulatory …	1/2
14 Apr 2014	Winifred Dennis 2014-0167 · Rebecca Cobb Patient transfers between community nursing teams lacked formal handover documents, resulting in critical information, like the need for specific equipment, not being …	South East Kent (North-East)	Kent Community Health NHS Trust	1/1
14 Apr 2014	Nicos Michael 2014-0168 · Rebecca Cobb The coroner identified conflicting evidence regarding the deceased's recorded allergies, noting a lack of readily available and continuously updated allergy information for …	South East Kent (North-East)	East Kent Hospitals University NHS …	1/1
13 Apr 2014	Lalitaben Patel 2014-0175 · Catherine Mason A locum consultant surgeon, despite being restricted to routine procedures, operated without additional supervision, raising concerns about oversight for consultants with identified …	East Midlands Leicester City & South Leicestershire	Department of Health and Social …	1/1
10 Apr 2014	Terence Dooley 2014-0162 · Jean Harkin The call concerning the deceased was given a code green despite the fact that each different tablet could be fatal on its …	North West Manchester City	North West Ambulance Service	1/1
29 Apr 2014	Janet Blackman 2014-0200 · Michael Burgess Psychiatric units fail to provide essential physical health care, including DVT prophylaxis, indicating a need for seamless, integrated care delivery for both …	South East West Sussex	Department of Health and Social … Sussex Partnership NHS Trust Western Sussex Hospitals NHS Trust	0/3
9 Apr 2014	Russell Long 2014-0165 · David Roberts The coroner identifies concerns regarding the damaged and overgrown parapet of a bridge, where displaced coping and end stones presented a hazard …	North West Cumbria (North & West)	Cumbria County Council	1/1
9 Apr 2014	Ozan Atasoy 2014-0166 · Edward Thomas A detained patient repeatedly absconded from a psychiatric unit's smoking area, often while escorted, indicating insufficient supervision and inadequate security protocols.	East of England Hertfordshire	Care Quality Commission	1/1
9 Apr 2014	Doris Taylor 2014-0164 · John Pollard The coroner noted that staff training should include a full and clear understanding as to what constitutes a reportable incident and the …	North West Manchester (South)	Borough Care Limited	0/1
9 Apr 2014	Michael Anthony 2014-0161 · Andrew Harris The coroner noted that the deceased's Gabapentin level was five times the normal therapeutic level, the reason for which was undetermined, and …	London London (Inner South)	Guy’s Hospital Princess Street Practice	1/2
9 Apr 2014	Thomas Allen 2014-0160 · Peter Dean The illegal practice of 'fly grazing' is difficult to manage in England as it is not a criminal offence, and a necessary …	East of England Suffolk	Department for Environment, Food and … Suffolk Constabulary	1/2
9 Apr 2014	Stephen Bedford 2014-0159 · David Morris Ambulance staff training and assessment for life support standards are inconsistent, leading to inappropriate crew deployment for critical patients and inadequate communication …	East of England Cambridgeshire (South & West)	East of England Ambulance NHS … Messrs Hempsons Messrs Stewarts Law LLP	0/3
9 Apr 2014	Sally Perrons 2014-0158 · Heidi Connor No specific concerns were detailed in the provided text for summarization.	East Midlands Nottinghamshire	Association of Ambulance Chief Executives East Midlands Ambulance Service NHS …	1/2
8 Apr 2014	Leslie Harding 2014-0169 · Andrew Cox There was a failure to take prompt action and ensure robust treatment for a patient with a suspected life-threatening pulmonary embolus over …	South West Plymouth, Torbay & South Devon	Oak Side Surgery	1/1
8 Apr 2014	Andrew Horgan 2014-0163 · David Ridley Doctors lacked clear understanding and training on mental health referral procedures, leading to inadequate patient assessment processes.	South West Wiltshire & Swindon	Great Western Hospital	1/1
8 Apr 2014	Frederick Hall 2014-0156 · John Pollard Widespread deficiencies included poor staff training for NG tube insertion, erratic patient monitoring, failure to follow consultant instructions, and significant communication breakdowns. …	North West Manchester (South)	Alexandra Hospital	0/1
8 Apr 2014	Audrey Kelly 2014-0155 · John Pollard The coroner reported that the attending doctor and nurse at the Out of Hours Service could not access the patient's GP electronic …	North West Manchester (South)	Department of Health and Social …	2/1
7 Apr 2014	Roger Duggan 2014-0157 · Elizabeth Earland An agitated patient was left unsupervised in the Emergency Department, and staff failed to take responsibility for monitoring him, leading to his …	South West Exeter & Greater Devon	Royal Devon and Exeter Hospital …	2/1
7 Apr 2014	William Winter 2014-0154 · Rachel Redman Understaffing and unfamiliarity with escalation procedures on a Clinical Decisions Unit led to missed patient observations and delayed surgical review.	South East Kent (Central & South East)	East Kent Hospitals University NHS …	0/1
7 Apr 2014	Jamie Barlow 2014-0153 · Peter Dean There was a lack of effective inter-agency working, clear protocols for police assistance, and a joint mental health assessment framework for high-risk …	East of England Suffolk	Norfolk and Suffolk NHS Foundation … Suffolk Constabulary	0/2