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 310 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
3 Feb 2014	Amanda Vickers 2014-0052 · D LI Roberts A severe shortage of specialist crisis home beds, with no clear availability, contributed to a patient's death while awaiting admission, highlighting inadequate …	North West Cumbria (North & West)	NHS Cumbria Clinical Commissioning Group	1/1
3 Feb 2014	Amy Friar 2014-0051 · Richard Travers The absence of universal emergency codes across the prison estate creates confusion for transferring staff, risking delays in emergency response.	South East Surrey	Ministry of Justice	0/1
3 Feb 2014	Daniel Jones 2014-0049 · Stephen Nicholls Insufficient road signage, including warning triangles and white arrows, at a specific junction on the A356 creates a hazard, necessitating improved signage …	South West Dorset	Dorset Highways Management	1/1
3 Feb 2014	Michael Telford 2014-0045 · D LI Roberts The coroner notes that water spilling onto a road from an adjacent field constitutes a regular hazard, likely exacerbated in freezing weather, …	North West Cumbria (North & West)	Cumbria County Council	0/1
31 Jan 2014	William Kent 2014-0056 · Karen Henderson Staff lacked awareness and received insufficient training on the harmful side-effects of Haz-Tab granules when used with urine, compounded by unclear usage …	South East Surrey	Guest Medical Medicines and Healthcare Products Regulatory … St Peter’s and Ashford Hospitals	0/3
31 Jan 2014	Ryan Chapman 2014-0048 · Penelope Schofield Staff lacked understanding of patient leave policies and support worker roles. Delayed risk assessments, insufficient family information, and poor ward security were …	South East West Sussex	Sussex Partnership NHS Trust	0/1
31 Jan 2014	Lee Bonsall 2014-0044 · Jonathan Layton Citalopram was inappropriately given on repeat prescription, contravening guidelines. Moreover, long ten-month waiting times for psychotherapy make it an unviable treatment alternative.	Wales Carmarthenshire & Pembrokeshire	Department of Health and Social …	2/1
31 Jan 2014	Shaun Elliott 2014-0042 · Richard Hulett The coroner noted that a missing person coordinator was not in post at weekends, that Shaun's family expressed a number of concerns …	South East Buckinghamshire	College of Policing	0/1
30 Jan 2014	Tallulah Wilson 2014-0047 · ME Hassell Healthcare professionals lacked sufficient understanding of young people's evolving internet use and online lives. Digital lives training is not standard for psychiatric …	London London Inner (North)	Department of Health and Social …	1/1
30 Jan 2014	Gareth Slater 2014-0050 · Joanne Kearsley Discharge planning failed due to clinical impasses, resulting in no care plan, insufficient family involvement, inadequate independent living assessment, and an unsuitable …	North West Manchester (South)	Oldham Borough Council Pennine Care NHS Foundation Trust	0/2
30 Jan 2014	Leslie Pates 2014-0043 · John Pollard A complete breakdown in hospital and social services communication with the family occurred. The patient was discharged against family wishes with severe …	North West Manchester (South)	Tameside Metropolitan Borough Council Tameside NHS Foundation Trust	1/2
16 Oct 2013	John James Jackson 2013-0260 · Robin Balmain The coroner notes a lack of readily available information about the dangers of consuming large quantities of caffeine, particularly from 'Hero Energy …	West Midlands Black Country	Department of Health and Social …	0/1
21 Oct 2013	Brian Belfield 2013-0270 · Robert Chapman Failures in race management included an inaccurate system for tracking participants, lack of a single responsible person for checks, and unreliable communication …	North West Cumbria (North and West)	Fell Runners Association	0/1
9 Sep 2013	Martin Daffydd Barker 2013-0226 · Joanne Kearsley There appears to be no national guidance on how independent medical service providers, particularly those covering large public events, should operate, posing …	North West Manchester South	Department of Health and Social … Manchester Medical Service North West Ambulance Service NHS … Salford Royal Hospital NHS Trust	2/4
17 Sep 2013	Neil Richard Clark 2013-0231 · Michael Snell A patient who had attempted overdose and undergone a mental health assessment was able to leave an Ambulatory Care Unit unnoticed, subsequently …	West Midlands Birmingham and Solihull	Jurys Inn Birmingham	0/1
27 Feb 2014	Maureen Leaver 2014-0036 · Karen Henderson Inadequate medical supervision and ineffective systems for investigating acutely ill elderly patients in a psychiatric ward were identified, alongside a lack of …	South East West Sussex	Sussex Partnership NHS Foundation Trust	0/1
27 Jan 2014	Pamela Bailey 2014-0040 · Donald Coutts-Wood Delays in implementing improved door security, inadequate weekend staffing, and the lack of a patient photograph for police when she disappeared, were …	Yorkshire and the Humber South Yorkshire (West)	Sheffield Trust	0/1
27 Jan 2014	Judith Marshall 2014-0039 · William Coverdale The pharmacy showed unpoliced drug errors and dispensing mistakes despite checks. Concerns include lack of alert software, mandatory read-back procedures, and a …	Yorkshire and the Humber York	Department of Health and Social … General Pharmaceutical Council NHS England Royal Pharmaceutical Society of Great …	4/4
27 Jan 2014	Umul Audu 2014-0038 · R Brittain The lack of transport heater availability during patient transfers risks future patients suffering hypothermia, potentially leading to death.	London London Inner (North)	University College London Hospitals NHS …	1/1
18 Oct 2013	Elizabeth Aurora Kerr 2013-0276 · Nigel Meadows The provided text is truncated, making it impossible to identify the specific safety concerns raised by the All-Party Parliamentary Gas Safety Group.	North West Manchester City	All Party Parliamentary Gas Safety … Association of Chief Fire Officers Department for Energy and Climate … Greater Manchester Fire and Rescue …	0/9