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 304 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
4 Apr 2014	Eric Matthews 2014-0151 · R Brittain There is limited public awareness and insufficient research regarding the risk of positional asphyxia associated with baby slings.	London London Inner (North)	University College London Hospitals NHS …	1/1
3 Apr 2014	Danuta Corbett 2014-0150 · Veronica Hamilton-Deeley The hospital's leave policy for informal patients was not followed, and inadequate risk assessment for escorted leave, using an untrained agency worker, …	South East Brighton & Hove	Sussex Partnership NHS Foundation Trust	1/1
3 Apr 2014	Graham Watts 2014-0149 · Veronica Hamilton-Deeley The hospital's discharge procedure was severely flawed, involving blank paperwork, lack of communication with family or care home, and discharging a medically …	South East Brighton & Hove	Brighton and Sussex University Hospitals … Royal Sussex County Hospital Princess Royal Hospital	1/3
3 Apr 2014	Melvin Bandtock 2014-0147 · Andrew Tweddle A duty manager's decision not to grit roads based on inaccurate weather assessment led to dangerous conditions; improved information sharing and review …	North East County Durham & Darlington	Durham Constabulary Durham County Council	2/2
2 Apr 2014	William Watson 2014-0146 · Caroline Sumeray Poor road layout and obstructing hedgerows at a specific location compromise driver visibility, creating a significant road safety hazard.	South East Isle of Wight	Hampshire Constabulary Island Roads Isle of Wight Council	0/3
2 Apr 2014	John Dodd 2014-0145 · Andrew Thompson Inadequate patient monitoring, including missed INR checks and unreported temperature rise, coupled with significant delays in A&E medical assessment, compromised patient safety.	West Midlands Black Country	Dudley Group NHS Foundation Trust	1/1
1 Apr 2014	Oliver Hiscutt 2014-0152 · Sara Lewis Lack of mandatory formal paediatric child health training for GPs results in inadequate skills to assess and manage sick children effectively.	North West Manchester City	Department of Health and Social … General Medical Council Health Education England Royal College of General Practitioners	0/5
1 Apr 2014	Vincent Gibson 2014-0148 · Terence Carney Police incident management suffered from unclear leadership, inadequate communication protocols, ineffective resource allocation, and unreliable electronic aids, compromising response safety and efficiency.	North East Gateshead & South Tyneside	Independent Police Complaints Commission Northumbria Police	0/2
31 Mar 2014	Joseph Godfrey 2014-0143 · Nadia Persaud Care staff and paramedics lacked awareness of warfarin-related bleeding risks in elderly fall patients. Care home staff failed to follow observation protocols, …	London London (East)	BUPA Care Homes BUPA UK Provision	0/2
31 Mar 2014	Valerie Hancox 2014-0144 · John Ellery Farm bale chutes are routinely left lowered and unmarked on public highways, contrary to manufacturer instructions, posing a significant, unlit obstruction hazard …	West Midlands Shropshire, Telford & Wrekin	AGCO Ltd	0/1
31 Mar 2014	Deanne Smith 2014-0141 · Dr R N Palmer The practice of dispensing large quantities of methadone to drug-dependent individuals over public holidays increases the risk of future deaths and needs …	London London (South)	Bromley Drug and Alcohol Service United Pharmacy	1/2
28 Mar 2014	Rosemary Simpson 2014-0142 · Selena Lynch The bus stop's location in a busy area creates poor visibility for buses, forcing unsafe lane changes and posing risks to pedestrians …	London London Inner (North)	London Borough of Camden	0/1
28 Mar 2014	Susan Poore 2014-0140 · Jacqueline Lake Anti-depressant medication was associated with a deterioration in the patient's depression, leading to an uncharacteristic death, despite side-effect warnings.	East of England Norfolk	NHS England	0/1
28 Mar 2014	Sebastian Davies 2014-0139 · David Osborne Hourly night observations failed to check for patient immobility or movement, potentially delaying detection of unconsciousness, and lacked continuity among observing staff.	East of England Norfolk	Norvic Clinic	0/1
26 Mar 2014	Lee Hollman 2014-0135 · Karen Henderson The practice had inadequate systems for maintaining accurate medical records, removing outdated repeat prescriptions, and reviewing patients' medication within guidelines.	South East West Sussex	Horsham and Mid Sussex Clinical … Royal College of General Practitioners	2/2
25 Mar 2014	Caroline Pilkington 2014-0269 · Jennifer Leeming North West Ambulance Service staff lack control and restraint training, forcing reliance on police who are not clinically trained, leading to delayed …	North West Manchester (West)	Department of Health and Social … North West Ambulance Service	4/2
25 Mar 2014	Margaret Walker 2014-0134 · Jennifer Leeming Incomplete medication history, poor record-keeping, and failure to apply a defibrillator promptly by ward staff contributed to critical care delays.	North West Manchester (West)	5 Boroughs Partnership	1/1
24 Mar 2014	Sean Morley 2014-0132 · David Clark The A444 stretch lacks pedestrian/cyclist warning signs, street lighting, and protective barriers, despite regular use by vulnerable road users and a 70mph …	West Midlands Warwickshire	Warwickshire County Council	1/1
24 Mar 2014	Jackson Chadd 2014-0137 · Karen Henderson Concerns include inadequate supervision for junior paediatric staff, insufficient consultant oversight for out-of-hours admissions, failure to apply national guidelines for fever in …	South East Surrey	Department of Health and Social … Frimley Park Hospital Royal College of Paediatrics and …	2/3
24 Mar 2014	Phyllis Barnes 2014-0138 · Karen Henderson A visiting GP failed to recognise the seriousness of the patient's condition. Post-operative telephone follow-ups were inadequate, and there was no effective …	South East Surrey	Frimley Park Hospital NHS Trust North East Hampshire and Farnham … Royal College of Surgeons	0/3