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 307 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
3 Mar 2014	Kevin Pearson 2014-0086 · Paul Kelly The company potentially failed to ensure full compliance with health and safety guidance for drivers and verify their understanding of critical instructions …	Yorkshire and the Humber North Lincolnshire & Grimsby	John Somerscales Ltd	0/1
28 Feb 2014	Peter Norman Nott 2014-0229 · Nicholas Graham Care home staff failed to perform adequate neurological observations following a patient's fall, relying on simple visual checks despite prolonged immobility and …	South East Oxfordshire	Rush Court Nursing Home	1/1
28 Feb 2014	Richard White 2014-0085 · Crispin Oliver Hope House lacked a formal, documented policy or protocol for medication administration, which was unknown to prescribers and not made available to …	North East County Durham & Darlington	700 Club	1/1
28 Feb 2014	Nathan Douthwaite 2014-0084 · Andrew Tweddle A rectal biopsy would likely have diagnosed Hirschsprung's disease, highlighting concerns about current diagnostic guidelines and the trust's practices in this regard.	North East County Durham & Darlington	County Durham and Darlington NHS … Department of Health and Social … National Institute for Health and …	1/3
27 Feb 2014	Victoria Meppen-Walter 2014-0083 · Lisa Hashmi Concerns were raised regarding the easy online availability and regulation of chloroquine, along with the associated risks of its misuse.	North West Manchester (North)	Department of Health and Social … Medicines and Healthcare Products Regulatory …	0/2
27 Feb 2014	Malcolm Potter 2014-0082 · Belinda Cheney The pedestrian crossing's warning light system is inadequately positioned and not synchronized for multiple trains, creating a significant re-crossing risk on a …	East of England Cambridgeshire (South & West)	Network Rail	0/1
26 Feb 2014	Sean Cunningham 2014-0087 · S P Fisher A persistent design flaw in ejection seats allows strap misrouting, posing a significant risk, and manufacturers lack a robust system for urgently …	East Midlands Lincolnshire (Central)	Martin-Baker the MOD	0/2
26 Feb 2014	Herta Woods 2014-0081 · Veronica Hamilton-Deeley Multiple failures in patient care included apparent abandonment, poor documentation, lack of senior review, incorrect fluid management leading to overload, and inappropriate …	South East Brighton & Hove	Brighton and Sussex University Hospitals	0/1
26 Feb 2014	Bertram Hamilton 2014-0080 · Robin Balmain The coroner was concerned that a nurse appeared not to know that insulin should not be given to a person whose blood …	West Midlands Black Country	Nursing and Midwifery Council	0/1
26 Feb 2014	Hazel Polkinghorn 2014-0078 · Stuart Fisher The easy online acquisition of dangerous non-prescribed medication, like Pentobarbital, poses a significant risk of future deaths, necessitating government intervention to regulate …	East Midlands Central Lincolnshire	Ministry of Justice	0/1
26 Feb 2014	Samuel Shaw 2014-0076 · Tony Brown Pedestrians crossing a 60mph unlit trunk road from a holiday park face extreme danger due to poor visibility, lack of warning signs …	North East North Northumberland	National Highways	1/1
26 Feb 2014	Sidney Harvey 2014-0075 · Siobhan Kelly Non-safety glass doors in rented properties, particularly where vulnerable individuals reside, pose a risk, and there is no clear system for their …	East Midlands South Lincolnshire	South Kesteven District Council	0/1
25 Feb 2014	Stephen Palmer 2014-0072 · Veronica Hamilton-Deeley Multiple failures, including delayed assessments, lack of senior review, inappropriate unit transfer, and a complete CT scanning service failure, led to critical …	South East Brighton & Hove	Brighton and Sussex University Hospitals	0/1
25 Feb 2014	Andre Matei 2014-0089 · Andrew Walker The coroner noted the lack of national guidance on the role of interpreters during labour, particularly when an interpreter is required in …	London London (North)	Department of Health and Social …	1/1
25 Feb 2014	Lee Curran 2014-0079 · Jennifer Leeming PPO recommendations for high cholesterol and loss of consciousness protocols were not fully implemented, with NICE guidelines ignored by doctors. Additionally, prison …	North West Manchester (West)	Department of Health and Social … HMP-YOI Forrest Bank Ministry of Justice HM Prison and Probation Service	0/5
25 Feb 2014	Arthur Brockett-Deakins 2014-0077 · Andrew Harris Midwives failed to timely escalate abnormal CTG results due to misapplication of guidelines and inadequate training. Concerns also arose about CTG machines …	London London (Inner South)	Department of Health and Social … General Midwifery Council Medicines and Health Regulatory Authority National Institute for Health and …	4/4
25 Feb 2014	Rachel Burke 2014-0074 · Andrew Harris An adventure company misrepresented ascent altitudes, leading to unsafe rates for altitude sickness prevention. The trek leader prioritized cost over urgent medical …	London London (Inner South)	ABTA - The Travel Association Himalayan Encounters Ministry of Culture, Tourism and … Adventure Company	1/6
24 Feb 2014	James Sutton 2014-0090 · Andrew Walker The London Ambulance Service failed to automatically link multiple risk factors—a 5-foot fall, patient age over 50, and anti-clotting medication—to trigger an …	London London (North)	Department of Health and Social …	0/1
24 Feb 2014	Kenneth Aldridge 2014-0071 · Peter Bedford The design of a service road access on a 70 mph dual carriageway requires dangerous manoeuvres like significant slowing or U-turns, posing …	South East Berkshire	West Berkshire Highways Authority	1/1
24 Feb 2014	Mark Burgess 2014-0069 · Michael Singleton The M65 motorway's decommissioned lighting system meant drivers could not see debris in the unlit carriageway, directly causing multiple subsequent collisions and …	North West Blackburn, Hyndburn & Ribble Valley	National Highways	0/1