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 309 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
21 Nov 2013	Lisa Jane Clayton 2013-0309 · Lisa Hashmi Inadequate physical deterrents on a car park wall, insufficient CCTV monitoring and understaffed security, coupled with a history of similar incidents, highlight …	North West Manchester North	Kennedy Wilson Europe (as Landlord) Public Protection, Oldham Council, Chadderton … Savilles Management Resources (as the … The Spindles Town Square Shopping …	0/4
21 Feb 2013	Jack William Partington 2013-0308 · Lisa Hashmi Neonatal care suffered from inadequate nurse handovers, isolated treatment decisions, and a lack of routine exhaled carbon dioxide detector use. There were …	North West Manchester North	Department of Health Pennine Acute Hospitals NHS Trust	1/2
20 Feb 2014	Benjamin James Carroll 2014-0068 · Wendy James The road remained open to traffic during a cycling race sprint towards the finish line, despite accredited marshals with powers to stop …	Wales Gwent	Welsh Cycling	1/1
19 Feb 2014	Simon McAndrew 2014-0067 · Dr R N Palmer Poor communication between different NHS Trusts, particularly regarding mental health and drug misuse information, resulted in important details being missed, inappropriate referrals, …	London London (North)	Central and North West London …	0/1
18 Feb 2014	Jack Lynn 2014-0066 · Tony Brown The absence of a continuous medication communication record and a safety/well-being check during a 15-minute care visit exposed the patient to potential …	North East North Northumberland	Nightingale Home Help Service	1/1
17 Feb 2014	Selina Broadhurst 2014-0065 · John Pollard Strict adherence to NICE Guidelines regarding CT head scans, which don't recommend scans without obvious neurological signs, is causing delayed or missed …	North West Manchester (South)	National Institute for Health and …	0/1
17 Feb 2014	Laura Hill 2014-0064 · Joanne Kearsley Despite existing training, Falls Risk Assessments were not carried out for the patient during her entire hospital stay, including upon admission and …	North West Manchester (South)	Stockport NHS Foundation Trust	1/1
13 Feb 2014	John Davies 2014-0063 · Dr Fiona Wilcox GMC investigations are causing unrecognised psychological distress in clinicians, underscoring the need for improved communication, support resources, and proactive assessment for suicidal …	London London Inner (West)	General Medical Council Medical Protection Society Royal College of Physicians	0/3
13 Feb 2014	Lisa Inkin 2014-0062 · Dr Fiona Wilcox A severe shortage of local specialist psychiatric beds, critical communication failures between services, and inadequate staff training led to delayed escalation of …	London London Inner (West)	Cygnet Healthcare Kent and Medway Mental Health … NHS England	0/3
12 Feb 2014	Refat Hussain 2014-0061 · Dr Fiona Wilcox Out-of-hours GPs working for Harmoni lack access to patients' full medical records, compromising their ability to make accurate diagnoses.	London London Inner (West)	Harmoni HS	1/1
12 Feb 2014	Georgina Swindells 2014-0060 · R Brittain The coroner identified concerns regarding delays in image transfer, a lack of available data to investigate the issue, the absence of an …	London London Inner (North)	Radiology Reporting Online LLP University College London Hospitals NHS …	0/2
7 Feb 2014	Adrian Cowan 2014-0111 · Andrew Walker The trust's emergency policy lacked clear guidance and a requirement to call a duty doctor, and nursing staff were unable to calmly …	London London (North)	Barnet Enfield and Haringey Mental … North London Forensic Service	1/2
7 Feb 2014	John Grooby 2014-0054 · S McGovern A lack of signage warning motorists about deer using a specific area as a "game track" creates an avoidable road safety hazard.	West Midlands Warwickshire	Warwickshire County Council	1/1
6 Feb 2014	Brian Kent 2014-0053 · Dr R N Palmer No specific concerns are detailed in the provided text.	London London (South)	Italian Embassy	0/1
5 Feb 2014	Keith Martin 2014-0055 · Karen Henderson Systemic delays in A&E assessment, diagnostics, senior review, and treatment for chest pain, combined with unclear protocols and poor documentation, resulted in …	South East Surrey	St Peter’s and Ashford Hospitals	0/1
4 Feb 2014	Neil Blood 2014-0183 · Ian Smith A lack of regulatory oversight, risk assessment, and consumer warnings for pedal cycle cleats and shoes raises concerns about potential dangers to …	West Midlands Stoke-on-Trent & North Staffordshire	Department for Transport Shimano Inc	0/2
4 Feb 2014	Samuel Boon 2014-0046 · Selena Lynch The expedition lacked adequate risk assessments, failed to provide sufficient pre-trip information, neglected to formally assess participant fitness, and did not train …	London London (South)	Department for Education	0/1
3 Feb 2014	Scarlett Sinclair 2014-0059 · Maria Voisin The policy for assessing a baby's wellness and stability prior to transfer between neonatal units needs urgent review, as babies are being …	South West Avon	Oxford University Hospitals NHS Trust	0/1
3 Feb 2014	Daniel Collins 2014-0058 · Ian Arrow The provided text indicates that matters of concern were revealed but does not detail what these specific concerns are.	South West Plymouth, Torbay & South Devon	Devon and Cornwall Police Plymouth City Council	0/2
3 Feb 2014	Ryan Clark 2014-0057 · Melanie Williamson Prison procedures like the Personal Officer Scheme, ACCT checks, and roll call were not properly implemented. Additionally, prison officers lacked sufficient first …	Yorkshire and the Humber West Yorkshire (East)	HM Prison and Probation Service	2/1