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 311 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
23 Oct 2013	Jacqueline Allwood 2013-0275 · Andrew Harris The urgent care center lacked an agreed protocol for DVT management, and a consulting GP failed to meet normative practice standards for …	London London (Inner South)	Bromley Healthcare Cator Medical Centre Beckenham Beacons UCC General Medical Council	1/5
20 Sep 2013	Joan Mary Jones 2013-0234 · Catherine Mason Care home staff failed to escalate a patient's deteriorating condition and provide complete information to health professionals, resulting in inadequate care and …	East Midlands Leicester City and South Leicestershire	Manor Residential and Nursing Care …	1/1
16 Sep 2013	George Renshaw Brown 2013-0230 · John Pollard A lack of efficient systems for reassessing and transferring care home residents with rapidly deteriorating conditions led to significant delays in moving …	North West Manchester South	Bromleys Solicitors Care Quality Commission Fentons Solicitors Manchester Clinical Commissioning Group	0/6
26 Jan 2014	Lillian Robinson 2014-0041 · Martin Flemimg The report text did not detail specific concerns, only indicating that matters giving rise to a risk of future deaths were identified.	South East Surrey	Surrey County Council	0/1
9 Sep 2013	Ricky Anderson 2013-0227 · Patricia Harding Mental health services failed to inform the GP of hospital admissions, relied excessively on family for post-discharge monitoring, and discharged a patient …	South East Mid Kent and Medway	Kent and Medway NHS Social Care Partnership Trust	0/2
12 Sep 2013	Matthew Dunham 2013-0229 · William Armstrong Failures in mental health care included delayed emergency referrals, unclear team roles, inadequate assessment of suicide risk, and critical breakdowns in information …	East of England Norfolk	Norfolk and Suffolk NHS Foundation …	0/1
19 Sep 2013	Tripta Rani Kumar 2013-0235 · Chinyere Inyama A patient with a documented penicillin allergy was prescribed penicillin-containing medication after a critical allergy note was incorrectly overwritten without authorisation, creating …	London London Eastern	Queen’s Hospital	0/1
11 Sep 2013	Caroline Lee 2013-0228 · S McGovern Medical staff failed to recognise the significance of abnormal potassium results, compounded by the laboratory's failure to inform ward staff promptly, hindering …	West Midlands Coventry	University Hospital Coventry and Warwickshire	0/1
17 Sep 2013	Margaret Theresa Corrigan 2013-0233 · John Pollard Ineffective communication, a missed fracture diagnosis in the Emergency Department, and inappropriate ward placement for medical issues contributed to patient harm. Procedural …	North West Manchester South	Stockport NHS Foundation Trust	0/1
24 Sep 2013	Jude Augustus Gordon 2013-0237 · Donald Coutts-Wood Failures in calculating and escalating Early Warning Scores, alongside a lack of national standardisation and automatic alert systems, led to delayed critical …	Yorkshire and the Humber South Yorkshire (West)	Department of Health and Social …	1/1
3 Oct 2013	Ishmail Kubilay 2013-0248 · Edward Thomas The Prison Ombudsman's clinic review identified healthcare deficiencies with national implications, but the specific recommendations are truncated in the provided text.	East of England Hertfordshire	Department of Health and Social … Ministry of Justice	0/2
17 Sep 2013	Alva Jullien 2013-0232 · John Pollard A lack of home assessment and poor communication between health professionals led to an unnecessary prolonged hospital stay, contributing to pneumonia, and …	North West Manchester South	Stockport NHS Foundation Trust	0/1
14 Oct 2013	Yousef Shokri-Gharab 2013-0239-wp23943 · Andre Rebello An outdated and unreviewed policy for informal patient leave failed to reflect current practice, risking patient safety due to lack of multidisciplinary …	North West Liverpool	Mersey Care, NHS Trust	1/1
18 Oct 2013	Jennifer Rushworth 2013-0264 · John Pollard Significant delays in cardiology reviews, lack of surgeon input in theatre booking, and insufficient surgeons contributed to surgical delays, potentially impacting patient …	North West Manchester South	Stepping Hill Hospital	0/1
25 Sep 2013	Gwilym Pugh Jones 2013-0239 · John Gittins Clinician-requested tests were not conducted, resulting in a missed opportunity for diagnosis and treatment.	Wales North Wales (East and Central)	Betsi Cadwaladr University Hospital Board	1/1
4 Oct 2013	George Leonard Parkes 2013-0252 · Sarah Ormond-Walshe Failure to follow up on a patient with an abdominal aortic aneurysm led to its rupture and death. A specialist nurse clinic …	West Midlands Birmingham and Solihull	University Hospitals Birmingham NHS Foundation …	0/1
14 Oct 2013	Frederick Davidson 2013-0258 · Martin Flemimg Inadequate note-keeping, inappropriate use of a nasogastric tube given the patient's history, unexplained gaps in clinical notes, communication breakdown between junior doctor …	South East Surrey	Department of Health and Social … Epsom and St Helier University …	0/2
8 Oct 2013	Anthony Bernard Mcormick 2013-0255 · Nigel Meadows Urgent blood test results were not acted upon promptly, leading to a delay in necessary hospital admission.	North West Manchester City	Consultant Physician and Gastroenterologists East Cheshire NHS Trust	0/2
24 Jan 2014	Bertha Cray 2014-0037 · R Brittain Inadvertent alteration of 'nil by mouth' signage is possible due to easily turned double-sided signs and an unclear cause of previous alteration, …	London London Inner (North)	Barts Health NHS Trust	1/1
24 Jan 2014	Elizabeth Turnbull 2014-0035 · Nicola Mundy The close proximity of thumbwheel controls, coupled with the absence of dual controls, increased the risk of inadvertently releasing locking pins for …	Yorkshire and the Humber South Yorkshire (East)	British Industrial Truck Association HM Principle Specialist Inspector	0/2