Kirk Duboise
AI-generated concerns summaryThe coroner noted a delay in summoning an ambulance and that relevant forms were not seen by staff assessing the risk of self-harm for a new prisoner.
Addressed to: Care UK; Prison Service
Source · Prevention of Future Deaths
Prevention of Future Deaths Reports
Browse 6,493 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
Luke Jacob Goodwin
AI-generated concerns summaryLarge helium canisters are readily available to the public without sales restrictions or control valves to limit gas release. The coroner also identified readily available online information that provides detailed guidance on how to commit suicide and links to purchase relevant products.
Addressed to: House of Commons
Peter Galea
AI-generated concerns summaryThe coroner noted limited mechanisms for agencies to break the cycle of referrals to allow for more detailed mental health assessments, and expressed concern about limitations on GPs directly admitting patients to a place of safety.
Addressed to: Department of Health
Peter Jeffrey
AI-generated concerns summaryThe coroner noted that after DVT was ruled out, no alternative effective diagnosis or treatment was considered. Additionally, no culture or swab was taken from an infected blister, and intravenous antibiotics were not considered.
Addressed to: Guy's and St Thomas' NHS Foundation Trust
John William Tugwell
AI-generated concerns summaryThe coroner noted that a resident identified as a falls risk, with a history of previous falls, was allowed unsupervised access to stairs within the care home.
Addressed to: Coombe Dingle Nursing Home
Jane Dyson Gabbitas
AI-generated concerns summaryThe SHARE accommodation unit lacked a clear system to record and monitor patient absences. This raised concerns that future deaths could occur if action is not taken to track and appropriately respond to prolonged or inappropriate absences.
Addressed to: South West Yorkshire Partnership NHS Foundation Trust; The Chief Coroner
Edna Elsie Mary Eden
AI-generated concerns summaryThe coroner identified delays in a patient receiving prescribed antibiotics and doctor review, alongside infrequent nursing observations and an incorrect EDOD score that prevented escalation. Communication gaps meant nurses struggled to contact doctors, and junior staff did not escalate significant backlogs or concerns.
Addressed to: Wexham Park Hospital Trust
Doris Phoebe Miller
AI-generated concerns summaryThe coroner noted inaccessible patient medical records at the GP surgery and a lack of effective communication between the GP practice and district nurses for urgent blood tests. The surgery also lacked a pulse oximeter.
Addressed to: Care Quality Commission; NHS England Hertfordshire and South Midlands Area
Barry James Lewis
AI-generated concerns summaryThe adequacy and availability of emergency surgical equipment in the ER, including appropriate sizes and out-of-hours theatre access, raised concerns. Also noted were night staffing levels for ODTs and ENT medical cover.
Addressed to: Pennine Acute Hospitals NHS Trust
Alan Stanfield Browning
AI-generated concerns summaryMr. Browning was discharged from Somewhere House without his family being informed of accommodation arrangements, and a Friday discharge limited time to secure proper housing. There was also a lack of clarity regarding routine family involvement in discharge planning.
Addressed to: Somewhere House
Lisa Jane Clayton
AI-generated concerns summaryConcerns involve the car park's 7th-floor wall design, which facilitates climbing, and inadequate CCTV monitoring and security staffing. Little action has been taken despite prior incidents at this location and previous concerns raised.
Addressed to: Kennedy Wilson Europe (as Landlord); Public Protection, Oldham Council, Chadderton Town Hall; Savilles Management Resources (as the Landlord's Managing Agent); The Spindles Town Square Shopping Centre
Jack William Partington
AI-generated concerns summaryConcerns noted inadequate neonatal nursing handover, care planning, and isolated treatment decisions. Also, a lack of national policies for paralysing agents in neonates and insufficient ventilatory pressure monitoring post-intubation.
Addressed to: Department of Health; Pennine Acute Hospitals NHS Trust
Benjamin James Carroll
AI-generated concerns summaryThe coroner noted that the road remained open to traffic during a cycling sprint towards the finish line, despite the presence of accredited marshals with powers to stop or direct traffic.
Addressed to: Welsh Cycling
Simon McAndrew
AI-generated concerns summaryThe coroner raised concerns about poor communication between different NHS Trusts, noting that important information regarding Mr McAndrew's psychiatric care was not effectively shared or accessed, leading to an inappropriate referral.
Addressed to: Central and North West London NHS Foundation Trust
Jack Lynn
AI-generated concerns summaryThe coroner noted the absence of a medication communication sheet at Mr Lynn's home, which prevented reliable checks on medication, and that a 15-minute visit did not include a check on his safety or well-being.
Addressed to: Nightingale Home Help Service
Selina Broadhurst
AI-generated concerns summaryThe coroner raised concerns that NICE Guidelines for head CT scans, which require obvious neurological signs, may lead to missed or delayed diagnosis of severe brain injuries in frail elderly patients.
Addressed to: National Institute for Health and Care Excellence
Laura Hill
AI-generated concerns summaryFalls Risk Assessments were not carried out for Mrs Hill during her hospital stay, specifically on admission or ward transfer, despite existing staff training on the procedure.
Addressed to: Stepping Hill Hospital
John Davies
AI-generated concerns summaryThe coroner noted that doctors undergoing General Medical Council investigations may experience adverse psychological effects that are unrecognised and unsupported. The report suggests considering communication tone, providing information on support agencies, and assessing for suicidal or self-harming behaviour.
Addressed to: General Medical Council; Medical Protection Society; Royal College of Physicians
Lisa Inkin
AI-generated concerns summaryThe coroner raised concerns about the shortage of local psychiatric beds, communication gaps between services and out-of-area providers, and insufficient staff training and escalation protocols regarding suicidal intent at Cygnet ward.
Addressed to: Cygnet Health Care; Kent and Medway Mental Health Directorate; NHS England
Refat Hussain
AI-generated concerns summaryThe coroner noted that out-of-hours GPs working for Harmoni lacked access to patients' GP medical records, which reduced their ability to make accurate diagnoses.
Addressed to: Harmoni HS