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 314 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
25 Sep 2013	Amna Umer Ahmed 2013-0241 · Andrew Harris Low awareness of Sudden Arrhythmic Death (SAD) among GPs and a lack of clear guidelines for urgent referral of at-risk patients contribute …	London London (Inner South)	British Cardiovascular Society Royal College of General Practitioners	1/2
20 Aug 2013	Derek Brierley 2013-0244 · Simon Nelson The suprapubic procedure was performed by a consultant after a long hiatus with inadequate preparation, likely incorrect insertion, and a lack of …	North West Manchester North	England & Wales Pennine Acute Trust	1/2
24 Sep 2013	Linda Hudson 2013-0243 · Andrew Tweddle Hospital discharge of a high-risk patient without family notification, inadequate communication regarding medication protocols, and a delayed nurse follow-up visit created significant …	North East County Durham and Darlington	Tees, Esk and Wear Valleys …	0/1
27 Dec 2013	Simon Sankey 2013-0361 · Alan Walsh The categorisation of mental health referrals was done by an unqualified administration assistant, with no subsequent review of the urgency category, and …	North West Manchester (West)	5 Boroughs Partnership NHS Foundation …	1/1
15 Nov 2013	Andrew Phrydas 2013-0301 · ME Hassell London Underground lacked a process for simultaneous dual-line shutdown at intersecting stations and failed to alert the train driver directly and effectively …	London London Inner North	London Underground	0/1
11 Nov 2013	William Joseph Wilkinson 2013-0294 · John Pollard Deficient one-to-one nursing, computer system failures, incomplete medical records, and absence of direct orthopaedic input in A&E contributed to an unnecessary admission …	North West Manchester South	Royal Bolton Hospital	0/1
18 Nov 2013	Stuart Aaron Collins 2013-0300 · Clare Bailey Inadequate patient assessment and a complete failure to conduct hourly observations or maintain accurate nursing notes for an epileptic patient. Furthermore, a …	North East Teesside	Cleveland Police Tees, Esk and Wear Valleys … James Cook University Hospital, South …	1/3
31 Oct 2013	John William Wright 2013-0285 · Gail Elliman A patient fall was not investigated as a Serious Untoward Incident, and there was unclear training for doctors on fall policy and …	London London Inner North	North Middlesex University Hospital NHS …	0/1
10 Oct 2013	James Edward Mansfield 2013-0288 · Mrs Cheney Delays in the GP surgery reviewing hospital discharge letters for serious injuries, combined with prescribing strong painkillers without an in-person assessment, posed …	East of England Cambridgeshire (South and West)	Nuffield Road Medical Centre	0/1
20 Dec 2013	Keith Samuel Peters 2013-0378 · Jennifer Leeming Inefficient case allocation and lack of prioritisation for assessments, combined with no system to reallocate cases when officers cannot meet deadlines, caused …	North West Manchester (West)	Bolton Council	1/1
20 Dec 2013	Kate Louise Pierce 2013-0363 · John Gittins A practicing GP failed to diagnose a patient and misled parents, with new evidence casting doubt on his fitness to practice. Previous …	Wales North Wales (East & Central)	General Medical Council	1/1
20 Dec 2013	Adrian Johnson 2013-0364 · Andrew Harris The coroner noted that initial screening did not assess for tobacco withdrawal, ACCT reviews lacked healthcare input, and there was a lack …	London London (Inner South)	HMP Belmarsh National Offender Management Service NHS England	1/3
20 Dec 2013	Roy Frank Fletcher 2013-0362 · Alan Wilson The Trust's post-incident review was inadequate, failing to interview a key witness or assess if similar events were persistent issues, thus hindering …	North West Blackpool & Fylde	Lancashire Care NHS Foundation Trust	0/1
14 Nov 2013	Anthony Brian Flynn 2013-0297 · Jennifer Leeming Seriously ill prisoners were inhumanely shackled during medical examinations, clinician concerns were ignored, and there was inadequate training for prison officers regarding …	North West Manchester West	Department of Health and Social … HMP Forest Bank	1/2
11 Nov 2013	John Gwynfryn Morris 2013-0295 · Edward Thomas Inadequate security measures at a residential dementia unit failed to prevent a resident with a known history of wandering from leaving the …	East of England Hertfordshire	Care Quality Commission	1/1
19 Dec 2013	Michael Longley 2013-0370 · Rachael Redman Difficulties in communication between Integrated Care 24 and the District Nursing Service highlight a need for improved oral and written communication methods.	South East Central & South East Kent	Kent Community Health NHS Foundation …	0/1
19 Dec 2013	Leo Deady 2013-0369 · Phillip Barlow A significant proportion of breech presentations go undiagnosed nationally, yet there are no national guidelines for routine late-pregnancy scans to detect them, …	London London (Inner South)	Department of Health and Social … Royal College of Obstetricians and …	1/2
19 Dec 2013	Kenneth Smalley 2013-0367 · Alan Walsh A malfunctioning operating table and emergency stop, potentially linked to a damaged, improperly positioned handset, highlight inadequate pre-operation checks and a lack …	North West Manchester (West)	Eschmann Holdings Limited Medicines and Healthcare Products Regulatory … Wrightington, Wigan and Leigh Teaching …	1/3
21 Nov 2013	Daniel Maurice McMahon 2013-0271 · Andrew Walker The report suggests improving information gathering by police when someone is trespassing on railway tracks; using feedback forms for patients on S17 …	London London	Department of Health and Social … LAS Legal Services Metropolitan Police RSSB	2/4
21 Oct 2013	Elsie Gibson 2013-0267 · Dr RN Palmer The Council, as Highways Authority, failed to promptly investigate and take action against an unlicensed scaffold tower that narrowed a pavement, leading …	London South London	Bromley Council	0/1