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 308 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
2 Dec 2013	Michael James Meyler 2013-0320 · Caroline Sarah Sumeray Prison systems failed to adequately circulate self-harm/suicide risk information to relevant staff and attach it to ACCT documents, leading to uninformed decisions …	North West Manchester City	HMPS HMP Manchester	1/2
2 Dec 2013	Karl Olof Nilsson 2013-0332 · Caroline Sarah Sumeray The junction's layout, gradient, and an obscured STOP sign created an optical illusion, making the sign difficult to perceive, which substantially contributed …	Yorkshire and the Humber West Yorkshire (Western)	National Highways Bradford Metropolitan District Council	1/2
5 Dec 2013	Karl Doran 2013-0328 · Andrew Tweddle The theme park failed to conduct appropriate risk assessments for volunteers, and there was a complete absence of direct or indirect managerial …	North East County Durham and Darlington	Beamish Museum HSE	0/2
22 Nov 2013	Garrett Joseph Franklin Elsey 2013-0316 · Terence G. Moore A document on people in commercial waste containers ('Waste 25') may not have been read widely in the waste industry, and an …	South West Avon	HSE's Waste and Recycling Sector …	0/1
4 Dec 2013	Keith Thomas Graham 2013-0327 · D.Ll. Roberts The report identifies a need to review procedures for seriously injured trauma patients arriving at the A&E, including summoning clinicians, CT scanning …	North West North and West Cumbria	North Cumbria University Hospitals NHS …	0/1
4 Dec 2013	Marjorie Evelyne Keogh 2013-0325 · Donald Coutts-Wood The care home failed to assess suitability for a first-floor room, had staffing level concerns, and a manager was often absent. Conflicting …	East Midlands Leicester City and South Leicestershire	Mymill Ltd. c/o Scraptoft Court …	2/1
6 Dec 2013	Keith Barton 2013-0330 · Patricia Harding There was a lack of clarity in dysphagia supervision recommendations, insufficient training for all staff on dysphagia awareness, and a failure to …	South East Mid Kent and Medway	Ashley Gardens Nursing Home	1/1
3 Dec 2013	Agostino Costa 2013-0322 · M E Hassell Staff confusion over patient falls risk classification and junior doctors' lack of training in post-fall management created significant safety concerns, exacerbated by …	London Inner North London	The Whittington Hospital NHS Trust	0/1
3 Dec 2013	Abdullahi Sharif Abokar 2013-0323 · Mary Hassell Mental health staff failed to assess suicide risk due to misconceptions, and resuscitation efforts were critically compromised by inadequate airway management, unactivated …	London Inner North London	Camden & Islington NHS Foundation …	1/1
4 Dec 2013	Yuki Ivy Norman-Knight 2013-0321 · David Osborne Concerns include fragmented patient record access, lack of clear guidelines for practice nurse referrals to doctors, and insufficient triggers for receptionists to …	East of England Norfolk	St Stephens Gate Medical Practice	1/1
6 Dec 2013	Kirk Duboise 2013-0329 · Andrew Tweddle There was a delay in summoning an ambulance and an inadequate self-harm risk assessment for a new prisoner, as essential forms were …	North East County Durham and Darlington	Care UK Prison Service	1/2
20 Nov 2013	Luke Jacob Goodwin 2013-0311 · Mary Teresa Burke The unrestricted sale of large helium canisters without flow control valves, combined with readily available online suicide guides, facilitates self-harm and raises …	Yorkshire and the Humber West Yorkshire (Western)	House of Commons	0/1
21 Nov 2013	Peter Galea 2013-0310 · Derek Winter Mental health services had limited mechanisms to break the 'ping pong' referral cycle between agencies, and GPs faced limitations in directly admitting …	North East City of Sunderland	Department of Health	0/1
27 Nov 2013	Peter Jeffrey 2013-0313 · Jacqueline Devonish Hospital staff failed to consider alternative diagnoses or treatments, did not take cultures from an infected blister, and overlooked intravenous antibiotics after …	London Eastern District of London	Guy's and St Thomas' NHS …	1/1
1 Dec 2013	John William Tugwell 2013-0319 · Martin Fleming The care home allowed a high-risk patient with a documented history of falls unsupervised access to stairs, despite the clear potential for …	South East Surrey	Coombe Dingle Nursing Home	0/1
12 Dec 2013	Jane Dyson Gabbitas 2013-0326 · Timothy Harvey Ratcliffe An open residential unit lacked a formal system to record and monitor resident absences, leading to staff being unaware of a resident's …	Yorkshire and the Humber West Yorkshire (Western)	South West Yorkshire Partnership NHS … The Chief Coroner	0/2
27 Nov 2013	Edna Elsie Mary Eden 2013-0317 · Peter James Bedford Significant delays in providing prescribed antibiotics, infrequent observations with an incorrectly calculated risk score, and failures in escalating concerns about patient review …	South East Berkshire	Wexham Park Hospital Trust	1/1
28 Nov 2013	Doris Phoebe Miller 2013-0318 · Tom Osborne Patient medical records were unavailable to the GP surgery after a practice closure, indicating a failure in transferring and making accessible essential …	South East Milton Keynes	Care Quality Commission NHS England Hertfordshire and South …	0/2
26 Nov 2013	Barry James Lewis 2013-0314 · Lisa Hashmi Critical deficiencies exist in the emergency department, including inadequate availability and consistency of emergency airway equipment, insufficient backup instruments, poor out-of-hours theatre …	North West Manchester North	Pennine Acute Hospitals NHS Trust	1/1
26 Nov 2013	Alan Stanfield Browning 2013-0315 · Simon Fox A vulnerable patient was discharged from a care facility without family notification or proper accommodation arrangements, specifically on a Friday, highlighting a …	South West Avon	Somewhere House	0/1