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.
Reports
| Date | Report | Responses identified |
|---|---|---|
| 11 Mar 2014 |
Saleh Ali Dalie
2014-0108 · Louise Hunt
This residential road has a history of multiple incidents and two fatalities, yet requested road calming, parking restrictions, and pedestrian crossing measures …
|
1/2 |
| 11 Mar 2014 |
Afifa Qaisar
2014-0107 · John Pollard
Critical issues included inaccurate drug administration records, missing emergency equipment, delays in urgent platelet transfusions, and a failure to properly monitor fluid …
|
0/1 |
| 11 Mar 2014 |
Lorna Cullen
2014-0105 · Allison Summers
The coroner raised concerns about long-term liaison psychiatry nurse staffing levels covering hospital emergency departments, after evidence indicated patients needing mental health …
|
0/2 |
| 11 Mar 2014 |
Christopher Shapley
2014-0121 · Christopher Woolley
Critical medical and self-harm risk information from police custody failed to transfer securely to the prison via the PER form, leading to …
|
0/2 |
| 10 Mar 2014 |
Craig Marren
2014-0106 · Kevin McLoughlin
Trees and foliage at a blind left-hand bend significantly impede driver visibility, creating a dangerous road hazard that requires cutting back.
|
1/1 |
| 10 Mar 2014 |
Derrick Rivers
2014-0104 · Lisa Hashmi
The care home had an inadequate, unspecific drugs administration protocol and lacked audit processes, with management unaware of non-compliance. Regulatory bodies also …
|
0/3 |
| 6 Mar 2014 |
Natasha Raghoo
2014-0100 · David Skipp
The coroner identified concerns regarding staff training in cardiopulmonary resuscitation and defibrillator use, sporadic physical observations, the lack of routine ECGs for …
|
1/2 |
| 5 Mar 2014 |
Neil Carter
2014-0103 · Sean Cummings
There were repeated failures in basic nursing observations, chronic inadequate staffing and skill mix, and deliberate falsification of nursing records, compounded by …
|
2/2 |
| 5 Mar 2014 |
Stephen Ellis
2014-0102 · John Pollard
A lack of warfarin home management kits for high-risk post-heart surgery patients leads to reliance on less efficient hospital monitoring.
|
0/1 |
| 5 Mar 2014 |
Nellie Travis
2014-0101 · John Pollard
The hospital's Falls Risk Assessment tool is ineffective due to its subjective nature and inconsistent application by nursing staff, highlighting the need …
|
0/1 |
| 5 Mar 2014 |
Barry Dillion
2014-0099 · Michael Singleton
Insufficient resources are available to provide a comprehensive Speech and Language Therapy service at the hospital, potentially impacting patient care.
|
0/1 |
| 5 Mar 2014 |
John Fox
2014-0098 · Fiona Wilcox
Reduced physiotherapy services on bank holidays and weekends increase the risk of post-operative complications for vulnerable patients.
|
0/1 |
| 4 Mar 2014 |
Ryan Pettengell
2014-0096 · Jacqueline Lake
Despite official closure and prior safety recommendations following multiple drownings, the site remains accessible to the public with damaged/missing signage and no …
|
0/4 |
| 4 Mar 2014 |
Kathleen Border
2014-0095 · David Horsley
Inadequate and unclear signage for parking areas led to a delivery vehicle reversing outside a designated zone, causing a fatal collision.
|
1/1 |
| 4 Mar 2014 |
Anne-Marie Katherine Ellement
2014-0181 · Nicholas Rheinberg
The Armed Forces' victim support code lacks specific provision for serious sexual assault victims within the military, and staff managing suicide vulnerability …
|
0/2 |
| 3 Mar 2014 |
Lee MacPherson
2014-0097 · Elizabeth Pygott
Delayed police risk assessments and a lack of common understanding between escort and prison staff regarding critical handover documentation posed significant safety …
|
0/4 |
| 3 Mar 2014 |
Marco Lima De Araujo
2014-0093 · David Horsley
There is no formal protocol for reporting and coordinating rescue efforts during life-threatening incidents in Portsmouth Harbour.
|
1/1 |
| 3 Mar 2014 |
Carl Morris
2014-0092 · Robert Chapman
Concerns are raised regarding gaps in the PADI system for auditing medical certificates for divers and ensuring instructors are alerted to and …
|
1/1 |
| 3 Mar 2014 |
Margaret Easterfield
2014-0091 · Rachel Redman
A rare anastomotic leak following surgery, leading to the patient's death, raises concerns about a potential technical error by the surgeon.
|
0/1 |
| 3 Mar 2014 |
Kirabo Kiwanuka
2014-0088 · Andrew Harris
Significant disagreement among medical professionals on Neuroleptic Malignant Syndrome diagnosis and management, leading to unclear optimal care pathways and limited family involvement …
|
0/2 |