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.

Reports

6,383 reports · Page 313 of 320
Date Report Region / area Addressee(s) Responses identified
13 Jan 2014 Zeeyad Hamadi
2014-0014 · Andrew Tweddle
Inadequate patient weighing and poor medical record-keeping within the prison were noted. There was limited liaison between prison and hospital staff, confusion …
North East
County Durham & Darlington
Department of Health and Social … National Offender Management Service 1/2
13 Jan 2014 Jason Nock
2014-0013 · Robin Balmain
An entirely unregulated product is readily available without consumer information on safe dosage or potential consequences, leaving users unaware of the substance …
West Midlands
Black Country
Home Office 1/1
13 Jan 2014 Michael O’Sullivan
2014-0012 · ME Hassell
The DWP assessment process for fitness to work failed to incorporate vital medical information from the patient's treating GP, psychiatrist, and clinical …
London
London Inner (North)
Department for Work and Pensions 1/1
10 Jan 2014 Mary Waldron
2014-0127 · R Brittain
Nursing home staff failed to recognise and act on an acutely unwell resident due to inadequate ongoing training and poor internal investigation. …
West Midlands
Coventry
Care Quality Commission Nursing and Midwifery Council St Mary’s Nursing Home West Midlands Ambulance Service University … 0/4
10 Jan 2014 Dr Edward Slaney
2014-0030 · Melanie Williamson
There is a lack of established criteria and guidance for planning authorities to assess the wind effects of tall buildings on the …
Yorkshire and the Humber
West Yorkshire (East)
Ministry of Housing, Communities & … 0/1
10 Jan 2014 Pauline Meredith
2014-0011 · Margaret Jones
Concerns include prolonged prescribing of excessive medication without review, adding morphine to a high-dose regimen for an alcohol-dependent patient, and a GP's …
West Midlands
Staffordshire South
Browning Street Surgery General Medical Council 1/2
9 Jan 2014 Albert James Hand
2014-0010 · Tom Osborne
The coroner reported concerns about a patient with a head injury waiting over an hour and a half for transport to hospital, …
East of England
Bedfordshire & Luton
East of England Ambulance Service 1/1
8 Jan 2014 Jonathan Thorpe
2014-0006 · John Pollard
A GP failed to consult or refer a known self-harmer to Mental Health Services, prescribing medication without adequate assessment of his ongoing …
North West
Manchester (South)
King Street Medical Centre 0/1
7 Jan 2014 Grace Mary Bates
2014-0007 · Andrew Walker
The hospital lacked a specialist diabetic nurse available over the weekend, posing a risk to patients requiring specific care.
London
London (North)
Barnet and Chase Farm Hospitals … Department of Health and Social … 2/2
7 Jan 2014 Andrew John Fallon
2014-0005 · John Pollard
Emergency Department staffing levels were critically insufficient, causing excessive delays for seriously ill patients as staff were overwhelmed by patient volume, including …
North West
Manchester (South)
Stockton NHS Foundation Trust 0/1
7 Jan 2014 James Withers
2014-0004 · John Pollard
Key concerns include significant delays in specialist consultation, missing medical notes, and poor communication with family regarding the Do Not Attempt Resuscitation …
North West
Manchester (South)
Tameside Hospital NHS Foundation Trust 0/1
6 Jan 2014 Daniel Williams
2014-0009 · Nicola Mundy
Key concerns include inadequate staff training in record-keeping and communication, absence of clear guidance for checking for self-harm items, and no central …
Yorkshire and the Humber
South Yorkshire (East)
Rotherham, Doncaster and South Humberside … 1/1
6 Jan 2014 Chloe Grace Flavell
2014-0003 · Maria Voisin
The reception area management, prior to triage, creates significant and dangerous delays in providing immediate care and treatment, particularly for children.
South West
Avon
Weston Area Health NHS Trust 0/1
6 Jan 2014 Billy Paul Thomas Salton
2014-0002 · Joanne Kearsley
GMP policy of not staffing the Prisoner Processing Unit overnight leads to unnecessary and prolonged custody times for individuals awaiting interview.
North West
Manchester (South)
GEO AMEY MEDACS Greater Manchester Police 2/3
6 Jan 2014 Martin McGlasson
2014-0001 · Robert Chapman
Widespread use of an unsafe work method, failure to implement inexpensive safety measures despite known risks, and inadequate dissemination of risk assessments …
North West
Cumbria (North & West)
British Precast Concrete Federation 1/1
3 Jan 2014 Keith Fleming
2014-0008 · Terence Carney
The provided text indicates that matters of concern were revealed but does not detail what these specific concerns are.
North East
Gateshead & South Tyneside
Newcastle upon Tyne Hospitals NHS … North of England Commissioning Report South Tyneside NHS Foundation Trust Trinity Medical Centre 0/4
31 Dec 2013 Adrian John Pickard
2013-0358 · Melanie Williamson
Company vehicles laden with aggregates are not routinely weighed before departing the premises, posing potential safety risks on public highways.
Yorkshire and the Humber
West Yorkshire (East)
Lightwater Quarries Limited 1/1
30 Dec 2013 Lynne Dring
2013-0360 · Paul Kelly
Street furniture obstructed motorists' views, and non-prescribed white lines may have falsely induced pedestrians to believe they had priority, creating a road …
Yorkshire and the Humber
North Lincolnshire & Grimsby
North East Lincolnshire Council 1/1
1 Oct 2013 Michael Joseph Hirrell
2013-0247 · Lydia Brown
Npower representatives did not recognise the deceased as a vulnerable person despite visible signs; personnel felt unable to halt disconnection; and Ofgem …
East Midlands
Leicester City and South Leicestershire
Energy UK Npower Ofgem 3/3
26 Sep 2013 Betty Grace Payne
2013-0242 · Mark Layton
Insufficient information sharing about vulnerable individuals with the Fire Service and a lack of training for Local Authority staff on home fire …
Wales
Carmarthenshire and Pembrokeshire
Carmarthenshire County Council County Hall Pembrokeshire County Council Hall 0/2
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