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 316 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
12 Dec 2013	William McCourt 2013-0383 · Robert Turnbull Local residents' reports of flooding were not recorded or acted upon, and maintenance staff failed to correctly identify land ownership, leading to …	Yorkshire and the Humber North Yorkshire (West)	1. David Bowe	1/1
12 Dec 2013	Rosemary Brownyn Ferguson 2013-0365 · Geoffrey Saul Poor communication between hospital staff and Social Services led to a discharge without support. Unclear instructions given to a friend regarding patient …	Yorkshire and the Humber South Yorkshire (East)	Doncaster and Bassetlaw Teaching Hospitals …	0/1
11 Dec 2013	Damion Stanley Joseph Henson 2013-0307 · Ian Smith A homeless unit, housing drug users, lacked 24-hour supervision, allowing unauthorized individuals to enter out of hours, thereby increasing risks in a …	North West Cumbria (South & East)	Riverview, 62 Lound Road, Kendal Riverview, 62 Lound Road, Kendal	0/2
9 Dec 2013	Anthony Hughes 2013-0352 · Andre Rebello Police officers lacked awareness of "excited delirium," suggesting that training on this condition could improve responses in future incidents, despite appropriate actions …	North West Liverpool	National Crime Agency	0/1
6 Dec 2013	Millie Elizabeth Thompson 2013-0356 · John Pollard Nursery staff lacked sufficient and updated paediatric first aid training. Ambulance call-takers misinterpreted breathing, causing incorrect triage, and emergency vehicles were inadequately …	North West Manchester (South)	North West Ambulance Service Trust Department for Education Department for Health	3/3
5 Dec 2013	Desmond Statton 2013-0379 · Andrew Cox The provided text describes a procedural step (blood sampling) but does not detail any specific concerns.	South West Plymouth, Torbay & South Devon	Derriford Hospital, Plymouth	0/1
3 Dec 2013	Horace Cottom 2013-0351 · Nigel Meadows The report identifies delays and incompleteness in the transfer of discharge information from NHS hospitals to prisons, a common issue resulting in …	North West Manchester City	Secretary of State for Health the NHS HMPS HMP Manchester	0/6
27 Nov 2013	Christopher Scott 2013-0350 · David Ridley The 'legal high' AMT is readily available for purchase despite clear evidence of its deadly effects, raising concerns about its unregulated status …	South West Wiltshire & Swindon	House of Commons	0/1
20 Nov 2013	Annie Jones 2013-0306 · John Gittins An inadequate mobility assessment led to the unsafe use of a stand aid for a non-weight-bearing resident. Staff lacked awareness of limitations …	Wales North Wales (East & Central)	Abbeydale Residential Home, Princes Drive, …	1/1
15 Nov 2013	David Cox 2013-0355 · Sophie Cartwright The narrow bridleway with acute, blind bends and no safety barrier poses a significant risk of vehicles leaving the track and falling …	East Midlands Derby & Derbyshire	The Peak District National Park …	1/1
14 Nov 2013	Kevin Paul Sutton 2013-0375 · Kevin Paul Sutton The Trust failed to prepare essential care plans for patients discharged from its wards to other establishments, risking inadequate ongoing care.	South West West Somerset	Somerset Partnership NHS Foundation Trust	0/1
14 Nov 2013	Dean Griffiths 2013-0299 · Rachel Redman Insufficient time allocated for exercises created pressure, preventing Range Conducting Officers from completing crucial final assurance checks.	South East Kent (Central & South East)	House of Commons	0/1
13 Nov 2013	Barnabas Newlyn 2013-0382 · Selena Lynch Road transfer times for time-sensitive critical care, particularly neurosurgical emergencies, are too long, necessitating earlier consideration and use of air transfer services.	London London Inner (North)	NHS England	1/1
11 Nov 2013	Timothy Clayton 2013-0361-wp26757 · ME Hassell Police improperly pressured the grieving family regarding organ donation, and an officer subverted the coroner's judicial decision, leading to the loss of …	London London Inner (North)	Kent Police	1/1
11 Nov 2013	Kathleen Rosemary Dixon 2013-0292 · Ian Smith Repeated critical incidents in the Trust, evident across multiple inquests, necessitate an independent assessment of its operations.	North West Cumbria (South & East)	Care Quality Commission Department of Health	1/2
7 Nov 2013	Stanley Dobson 2013-0303 · Martin Fleming Locum doctors failed to report patient non-response to the operative, hindering further contact efforts. Protocols need extending to ensure non-responses are consistently …	South East Surrey	ADC Surrey Harmoni	1/2
6 Nov 2013	Henry McQuoid 2013-0348 · G U Williams Insufficient staffing, particularly with high reliance on agency workers, meant some residents requiring eating assistance might not receive it.	West Midlands Worcestershire	Moundsley Hall Nursing Home	0/1
5 Nov 2013	Ethel Cross 2013-0362-wp25883 · Alan Wilson Wheeled chairs accessible to elderly patients caused falls, and a shortage of alarms for high-risk patients meant they could mobilize unsupported.	North West Blackpool and Flyde	Blackpool Teaching Hospitals NHS Foundation …	0/1
5 Nov 2013	Roshan Abbas Ladak-Ebrahim 2013-0278 · Andrew Walker Inadequate guidance on assessing self-harm risk, confusion regarding safeguarding responsibilities, and insufficient patient consultation when prescribing high-risk medication contributed to safety concerns.	London London (North)	Department of Health	1/1
4 Nov 2013	Susan Jill Hammond 2013-0286 · Stuart Fisher Critical allergy information was overlooked due to inadequate flagging on patient files, and a poor handover during transfer by an uninformed nurse …	East Midlands Lincolnshire (Central)	United Lincolnshire Hospital Trust	1/1