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 305 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
21 Mar 2014	Kerry Jacobs 2014-0133 · Bridget Dolan The hospital lacked a policy requiring doctors to document reasons for prescribing medication outside BNF guidelines. There was also no protocol for …	South East West Sussex	Surrey and Sussex NHS Trust	1/1
21 Mar 2014	Derrick Plater 2014-0130 · David Osborne There was no protocol for visiting care homes before placing patients with complex needs, relying solely on assurances. A lack of clear …	East of England Norfolk	Cambridgeshire County Council	1/1
21 Mar 2014	Norma Sheppard 2014-0129 · Andrew Haigh The report describes confusion regarding the terms of the deceased's discharge from hospital to the care home, specifically regarding the provision of …	West Midlands Staffordshire South	Queens Hospital Burton Upon Trent	0/1
20 Mar 2014	Robert Jones 2014-0190 · Jonathan Layton CT scan results were not made available promptly to relevant departments, nor were they acted upon without delay and within a reasonable …	Wales Carmarthenshire and Pembrokeshire	West Wales General Hospital Glangwili …	1/1
19 Mar 2014	Christopher Williams 2014-0131 · Alan Moore A critical defibrillator failed due to lack of daily checks and no cross-check system. The hospital also lacked a policy for managing …	North West Cheshire	St Mary’s Hospital Warrington	0/1
18 Mar 2014	David Chatburn 2014-0126 · L J Hashmi The GP failed to refer the patient to psychiatric services, inappropriately managed medication, and had poor record-keeping. Systemic issues included bureaucratic barriers …	North West Manchester (North)	Department of Health and Social … Pennine Care NHS Trust Rochdale Heywood and Middleton Clinical … York House Surgery	1/4
17 Mar 2014	Charles Bradley 2014-0118 · Andre Rebello Inadequate record-keeping and communication failures at Arrowe Park Hospital led to the patient not being expected upon transfer and unclear documentation of …	North West Liverpool	Arrowe Park Hospital	0/1
17 Mar 2014	Peter Banks 2014-0124 · Andrew Haigh A pedestrian crossing point was positioned too close to the main road. Protective railings should be extended and the crossing moved further …	West Midlands Staffordshire South	Casualty Reduction Team	0/1
17 Mar 2014	Daniel Taylor 2014-0125 · Andrew Haigh A specific downhill road section preceding a right-hand bend lacked appropriate warning signs or markings, warranting a review to prevent future collisions.	West Midlands Staffordshire (South)	Casualty Reduction Team	0/1
14 Mar 2014	David Oldfield 2014-0117 · Melanie Williamson Concerns were raised about the appropriateness and justification of tasering the deceased, given discrepancies in officer accounts. Unjustified tasering unnecessarily increases the …	Yorkshire and the Humber West Yorkshire (East)	West Yorkshire Police Force	1/1
14 Mar 2014	Michael Tarratt 2014-0115 · Lydia Brown There was an unacceptable 18-month lapse in communication between the drug and alcohol team and the GP. Services failed to exchange information …	East Midlands Leicester City & South Leicestershire	Leicestershire Partnership NHS Trust	1/1
14 Mar 2014	Gavin Roberts 2014-0120 · N J Mundy The current 60mph speed limit for a specific bend is too high, and warning signs are inadequate, particularly as the limit increases …	Yorkshire and the Humber Rotherham	Rotherham Metropolitan Borough Council	1/1
14 Mar 2014	Matthew Simmonds 2014-0119 · Grahame Short An effective local action plan for commissioning complex care pathways for ventilated patient discharges is not shared nationally, posing a risk that …	South East Hampshire (Central)	NHS England	0/1
13 Mar 2014	Janette Sutherland 2014-0114 · Wendy James A drainage channel and concrete headwall present a significant hazard to road users. A safety barrier is needed to prevent vehicles from …	Wales Gwent	Caerphilly County Borough Council	2/1
13 Mar 2014	Jean James 2014-0112 · Derek Winters Initial documentation delays and the unreviewed omission of prophylactic medication occurred. Pharmacy queries were poorly communicated, indicating that existing systems and protocols …	North East Sunderland	City Hospitals Sunderland NHS Foundation …	1/1
13 Mar 2014	Noel Williams 2014-0123 · Anthony Eastwood The coroner noted a failure to communicate haemoglobin level test results, which are an important factor in considering a patient's fitness for …	North East Teesside	South Tees NHS Trust	0/1
12 Mar 2014	Wendy Brown 2014-0113 · David Ridley Significant delays in implementing care packages and providing respite support for vulnerable carers, compounded by inadequate signposting of adult care services, complicated …	South West Wiltshire & Swindon	Swindon Borough Council	1/1
12 Mar 2014	Stephen Tilbury 2014-0109 · Nadia Persuad Excessive vehicle speed in a residential area, despite an existing trief curb, poses a significant risk as the curb can deflect speeding …	London London (East)	London Borough of Havering	0/1
12 Mar 2014	Andrew Hall 2014-0122 · Anthony Eastwood Inadequate communication and documentation of mental health risks, failure to administer prescribed medication, and insufficient patient observation within the prison healthcare unit …	North East Teesside	National Offender Management Service North Tees and Hartlepool NHS … Tees, Esk and Wear Valleys …	1/3
11 Mar 2014	Teresa Lonergan 2014-0110 · Andrew Harris The patient accumulated a dangerous hoard of prescribed controlled drugs due to a lack of monitoring by healthcare professionals, enabling a fatal …	London London (Inner South)	Eltham Park Surgery	0/1