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 315 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
1 Nov 2013	Andrew Cairns, Rachael Slack and Auden Slack 2013-0290 · Dr Robert Hunter Police failed to inform the Mental Health Team of an arrest for threats to kill despite knowing of a recent mental health …	East Midlands Derby and Derbyshire	Association of Chief Police Officers Department of Health and Social … Derbyshire Constabulary Derbyshire Healthcare NHS Foundation Trust	0/5
8 Nov 2013	Peter Patrick Adrian Barnes 2013-0291 · Neil Cameron Hospital systems were inadequate for communicating observed patient information and serious incidents from nursing staff to the Responsible Clinician, leading to incomplete …	Yorkshire and the Humber West Yorkshire (West)	Cygnet Healthcare Ltd.	0/1
30 Oct 2013	Winston Llewellyn Johns 2013-0279 · Louise Hunt Critical low blood sugar information was disregarded by the ambulance operator, and the computer system's inability to process clinical details led to …	Wales Powys Bridgend and Glamorgan Valleys	Department of Health and Social … Welsh Ambulance Service NHS Trust	0/2
1 Nov 2013	Joanne Manning 2013-0289 · Nadia Persuad A severe communication breakdown between GP and psychiatrist led to unsafe methadone prescribing without full patient information, compounded by the absence of …	London London	The Practice The Practice Practice	0/3
18 Dec 2013	Christine Williamson 2013-0371 · John Ellery Failure to assess the deceased as a vulnerable adult at risk from domestic violence and a critical lack of information sharing between …	West Midlands Shropshire, Telford & Wrekin	South Staffordshire and Shropshire Healthcare … Telford and Wrekin Clinical Commission … Telford and Wrekin Council West Mercia Police	3/4
30 Oct 2013	Damion Anthony Andre Martin 2013-0280 · Martin Fleming Inadequate prison risk assessment failed to identify a key suicide risk factor, first responders lacked CPR refresher training, and cell observation was …	North West Liverpool	NOMS HMP Liverpool Rights and Responsibilities Group	0/3
24 Oct 2013	Peter Clive Higson 2013-0277 · Michael Burgess Concerns arose regarding the detrimental effect of platelet transfusions following stem cell transplants, questioning if such transfusions might sometimes be contraindicated.	South East Surrey	Secretary of State for Health	2/1
21 Oct 2013	Lucy Kilvert 2013-0266 · Robin John Balmain A significant delay occurred in performing a CT scan for an elderly patient on blood thinners after a fall, suggesting NICE Guidelines …	West Midlands Black Country	National Institution for Health and …	0/1
24 Oct 2013	Harold Elvidge 2013-0274 · Heidi Connor A risk of fluid mix-ups exists due to inconsistent safety standards and storage policies across the trust, particularly in non-critical care settings, …	East Midlands Nottinghamshire	Nottingham University Hospitals NHS Trust	0/1
22 Nov 2013	Christopher James Morgan 2013-0272 · William Morris The Trust lacks clear policies for communicating risk level changes and leave access with family, and has no defined staff-to-patient ratio for …	East of England Cambridgeshire	Cambridgeshire and Peterborough NHS Foundation …	0/1
17 Dec 2013	Sean Seabourne 2013-0374 · Geraint Williams Systemic communication failures and unclear roles between mental health teams led to an urgent referral for a high-risk patient with suicide plans …	West Midlands Worcestershire	Worcestershire Health and Care NHS …	0/1
17 Dec 2013	Sandra Wordingham 2013-0373 · John Woolley A nursing home failed to seek timely medical opinion for an unconscious resident, delaying identification of a severe condition and risking unnecessary …	Wales Cardiff & the Vale of Glamorgan	Springbank Care Home Limited	1/1
17 Dec 2013	John Morgan 2013-0372 · John Woolley Over-reliance on whiteboards rather than patient notes, the potential for human error to input incorrect information, and the use of a misleading …	Wales Cardiff & the Vale of Glamorgan	Cardiff and Vale University Health … Welsh Government Health and Social …	1/2
17 Dec 2013	William Andrews 2013-0368 · Christopher Dorries Surgical equipment design flaws, including the lack of a brightly coloured detachable cap on a bulb syringe, led to a retained tip. …	Yorkshire and the Humber South Yorkshire (West)	Care Quality Commission Department of Health and Social … Secretary of State for Health	1/3
16 Dec 2013	Clive Gould 2013-0357 · Nicholas Graham Ambulance service failures include inappropriate priority allocation for calls, insufficient system resilience leading to delays, and inadequate communication with callers about estimated …	South East Oxfordshire	South Central Ambulance Service NHS …	1/1
16 Dec 2013	Joseph Drew Whiteside 2013-0377 · Andrew Haigh Numerous drownings of intoxicated individuals in the River Trent highlight the need for improved safety measures, such as fencing and warning signs, …	West Midlands Staffordshire (South)	East Staffordshire Borough Council	1/1
16 Dec 2013	Elsie May Treece 2013-0376 · Andrew Haigh Hospital staff likely failed to report an incident where a patient fell during transfer, suggesting a need for better training and reminders …	West Midlands Staffordshire (South)	Burton Hospitals NHS Foundation Trust	1/1
16 Dec 2013	Cynthia Fretwell 2013-0366 · Jane Gillespie The GP practice had an ineffective system for telephone referrals, lacking timely consultation, proper assessment of patient mental capacity for refusing treatment, …	East Midlands Nottinghamshire	HAMA Medical Centre, NHS Commissioning …	1/1
16 Dec 2013	Sarah Shepherd 2013-0359 · Alison Hewitt The Trust lacked a clear referral process for PICU and its documentation, while nursing staff misunderstood resuscitation guidelines due to unclear training …	South East Surrey	Surrey and Borders Partnership NHS …	0/1
13 Dec 2013	Stephanie Daniels 2013-0353 · Nigel Meadows Significant deficiencies exist in internal SUI investigations, with errors and omissions, along with concerns about the thoroughness and independence of inquiries. Additionally, …	North West Manchester City	APEX Nursing Agency Care Quality Commission Department of Health and Social … Greater Manchester Mental Health NHS …	3/8