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 312 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
24 Jan 2014	Lucy Goulding 2014-0034 · Karen Henderson There was insufficient consultant supervision and independent assessment for emergency paediatric admissions. A lack of national guidelines for assessing headaches in children …	South East West Sussex	Department of Health and Social … Royal College of Paediatrics and … Western Hospitals NHS Foundation Trust Worthing Hospital NHS Trust	1/4
24 Jan 2014	Alfred Hodges 2014-0033 · Nicola Jones Conwy's Telecare package lacks standard interlinked smoke alarms, and interim safety provisions are unclear. Additionally, the deceased was not offered a free …	Wales North Central & North East Wales	Conwy County Council	1/1
4 Sep 2013	Michael Irlam 2013-0224 · Andrew Bridgman A significant 24-day waiting time between discharge from crisis mental health services and the first follow-up appointment creates a dangerous gap in …	North West Manchester South	Improving Access to Psychological Therapies Trafford Crisis Resolution and Home …	0/2
23 Jan 2014	Desrae Tucker 2014-0032 · Wendy James Inadequate recording of anti-embolic stocking use, no consideration for discharging the patient with them, and failure to prescribe anti-coagulant medication upon discharge …	Wales Gwent	Aneurin Bevan Health Board	0/1
22 Jan 2014	Paul Rogerson 2014-0029 · William Coverdale River safety equipment is inadequate, poorly maintained, and lacks proper warning signs. Gaps exist in police river rescue training, inter-agency communication, and …	Yorkshire and the Humber York	City of York Council North Yorkshire Fire and Rescue … North Yorkshire Police	0/3
21 Jan 2014	William Dowling & Victoria Rose 2014-0027 · David Ridley There's no national system allowing doctors to proactively share concerns about a patient's ongoing suitability for a firearms license, with patient confidentiality …	South West Wiltshire & Swindon	Association of Chief Police Officers British Medical Association Firearms and Explosive Licensing Working … Hampshire Constabulary	0/8
21 Jan 2014	Mone White 2014-0031 · Andrew Walker There is no system to ensure specialist hospital advice for patients with complex clinical requirements is consistently communicated to all treating clinicians.	London London (North)	Department of Health and Social … Northwick Park Hospital	2/2
21 Jan 2014	Kyle Ashley Smith 2014-0028 · Jennifer Leeming An urgent mental health referral from a GP was significantly delayed in reaching the assessment team, with the reason for this critical …	North West Manchester (West)	Longshoot Health Centre	0/1
21 Jan 2014	John Malone 2014-0026 · John Pollard A hospital discharge letter was critically deficient, lacking essential patient admission and discharge details, which hindered the GP's ability to provide appropriate …	North West Manchester (South)	Tameside Hospital NHS Foundation Trust	0/1
21 Jan 2014	Christine Nutbeam 2014-0025 · Peter Bedford Critical information about a patient's symptoms was not transferred between hospitals or communicated to surgical teams, and pre-operative checks lacked a standard …	South East Berkshire	St Peter’s Hospital Wexham Park Hospital	0/2
21 Jan 2014	Frederick Pring 2014-0024 · John Gittins Current practices for patient handover at Emergency Departments lead to unacceptable delays, keeping ambulances occupied and unavailable for other critical calls.	Wales North Wales (East & Central)	Betsi Cadwaladr University Health Board	1/1
17 Jan 2014	Julie Ann Camm 2014-0023 · David Hincliff A vulnerable tenant's property lacked smoke alarms because the housing association's policy only encouraged fire safety checks, failing to ensure installation and …	Yorkshire and the Humber West Yorkshire (East)	Leeds City Council	1/1
17 Jan 2014	Julia Dell 2014-0021 · Andrew Cox The medical service received from primary care was exemplary during the period examined, with no concerns identified in the provided text.	South West Cornwall	Royal Cornwall Hospital Trust Medical Centre Stratton, Bude, Cornwall	0/3
17 Jan 2014	Wayne Broad 2014-0020 · Andrew Walker There is a lack of dedicated substance misuse teams in police custody and specialized nursing staff in hospitals. Police handcuffing policies for …	London London (North)	Association of Chief Police Officers Department of Health and Social … G4S Serco	1/4
16 Jan 2014	Jackie Scott 2014-0022 · Tony Brown Lack of clear allergen information meant the deceased unknowingly consumed peanuts in a take-away meal, resulting in a fatal anaphylactic shock.	North East North Northumberland	Indian Brasserie	0/1
16 Jan 2014	James Stokoe 2014-0019 · Derek Winter Mental Health Services lack formal mechanisms to consult carers/partners, potentially missing vital information that could inform risk assessments and identify domestic abuse, …	North East Sunderland	Department of Health and Social …	0/1
14 Jan 2014	Craig White 2014-0017 · ARW Forrest Concerns include insufficient TB screening protocols before Infliximab treatment, inadequate prescriber awareness of increased TB risk, and the need for better patient …	East Midlands South Lincolnshire	British National Formulary British Society of Gastroenterology Intensive Care Society Lincolnshire Community Health Services NHS …	0/7
14 Jan 2014	Russell James Felstead 2014-0016 · Joanne Kearlsey Doctors failed to access and read vital medical information within nursing notes, resulting in a four-day delay in ordering an urgent CT …	North West Manchester (South)	Care Quality Commission Stepping Hill Hospital Choice Support	0/3
13 Jan 2014	Mustafa Cicek 2014-0116 · Alan Craze Highway safety issues include a collision black spot with inadequate warning signage and a potentially hazardous eucalyptus sapling. "SLOW" warnings are also …	South East East Sussex	Department for Transport National Highways The Chief Coroner	1/3
13 Jan 2014	Barbara White 2014-0015 · Joanne Kearsley Critical lapses included a 12-hour absence of clinical observations, an incorrect PARS score that should have triggered intervention, and severe staff shortages. …	North West Manchester (South)	Tameside General Hospital	0/1