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 317 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
31 Oct 2013	Wilhelmina Isobel Newton 2013-0283 · David Roberts The care home lacked clear written protocols and guidance for staff on responding to head injuries in elderly residents, particularly those on …	North West Cumbria (North & West)	Cumbria County Council Carlisle Cumbria County Council Carlisle	1/2
23 Oct 2013	John Lansdowne 2013-0360-wp26756 · ME Hassell Unclear observation records and inconsistent staff understanding of patient observation protocols during bathing, coupled with the use of baths instead of safer …	London London Inner (North)	Camden & Islington NHS Foundation …	0/1
23 Oct 2013	Isabella Hope Hill 2013-0281 · Alan Wilson Hospital guidelines for umbilical venous catheter insertion, specifically requiring an X-ray to confirm position, were not followed, indicating sub-optimal practice and a …	North West Liverpool	Liverpool Womens Hospital	1/1
21 Oct 2013	Robert Wilkinson 2013-0269 · Andrew Tweddle The firearms certificate revocation process was inadequate, lacking a face-to-face meeting and personal service of the revocation letter, which contributed to the …	North East County Durham & Darlington	Durham Constabulary	1/1
21 Oct 2013	Mark Stephen Smith 2013-0268 · Andrew Walker Guidance is needed for emergency services on when to remain on the line with a person who has taken an intentional overdose …	London London (North)	London Ambulance Service	0/1
4 Dec 2013	Archibold Wellbelove 2013-0324 · R Brittain The Council failed to review its night-lighting policy for roads, creating unsafe conditions for pedestrians who regularly use unlit areas and may …	West Midlands Warwickshire	Warwickshire County Council	1/1
17 Oct 2013	Rosa Anderson 2013-0263 · Andre Rebello The patient was discharged without a summary, written information on her operation, critical advice, or emergency contact numbers.	North West Liverpool	Aintree Hospitals NHS Trust	1/1
17 Oct 2013	Brian Dorling and Philippine de Gerin-Ricard 2013-0265 · Mary Hassell Confusing unbordered blue strips for cyclists, insufficient education on safer riding techniques, and a dangerous junction contribute to increased road safety risks …	London London (Inner North)	Transport for London	1/1
16 Oct 2013	Janet Richardson 2013-0261 · David Roberts The deceased fell into the sea during a rescue medical evacuation.	North West Cumbria (North & West)	Cruise and Maritime Services International … Newmarket Promotions Limited Redningsselskapet	2/3
12 Oct 2013	Carol Ann Gibson 2013-0183 · Nicholas Rheinberg A GP ignored a critical adverse drug reaction alert, exacerbated by a culture of 'alert fatigue' and dismissive attitudes towards patient safety …	North West Cheshire	Castlefields Health Centre NHS England	0/2
8 Oct 2013	Kuldip Singh Dhillon 2013-0254 · Chinyere Inyama Widespread common practice of unrestrained palletised loads on vehicles poses significant safety risks, compounded by insufficient enforcement and auditing of transport regulations …	London London (East)	Department for Transport	0/1
4 Oct 2013	Jean James 2013-0207 · Andrew Cox Patients admitted via their GP experienced significant delays in medical review compared to those from the Emergency Department, with one patient waiting …	South West Cornwall	Rule 43 Archivist, Coroner Society … Office of the Chief Coroner Royal Cornwall Hospital	0/3
4 Oct 2013	Walter Gordon Powley 2013-0251 · Donald Coutts-Wood Uncovered, excessively hot pipes and radiator valves in a care home posed a burn risk. This was compounded by a lack of …	East Midlands Leicester City & South Leicestershire	Care Quality Commission Health and Safety Executive, Head … Registered Nursing Home Association	3/3
3 Oct 2013	Douglas Grey 2013-0253 · Chinyere Inyama Lack of clear written procedures for equipment delivery, installation, and review. Carers also failed to recognise and report faulty equipment despite a …	London London (East)	Consumer Relations and Legal Affairs Floron Residential Home	0/2
27 Sep 2013	Rose Jean Coles 2013-0246 · Maria Voisin Inadequate communication and protocols between the neonatal intensive care and cardiac units hindered the safe care of premature babies, as the cardiac …	South West Avon	University Hospitals Bristol NHS Foundation …	1/1
27 Sep 2013	Jared William McDowall 2013-0245 · Maria Voisin Inadequate guidelines for identifying at-risk babies, including a lack of specific weight-for-gestation criteria and poor data presentation. Joint training for doctors and …	South West Avon	University Hospitals Bristol NHS Foundation …	1/1
26 Sep 2013	Joan Farran 2013-0282 · Terence Carney The provided text is truncated and does not clearly state the specific concerns identified by the coroner.	North East Gateshead & South Tyneside	Safeguarding Adults Board Children, Adults & Families	0/2
25 Sep 2013	David Selman 2013-0354 · Nicholas Graham An ambulance delay resulted from a crew misunderstanding a 'stand down' order and crucial updated patient information not being relayed. This prevented …	South East Oxfordshire	South Central Ambulance Service	0/1
23 Sep 2013	Michael Sweeney 2013-0236 · ME Hassell Police training on 'excited delirium' is not widely understood by other health professionals, risking miscommunication and missed diagnoses of underlying medical conditions. …	London London North (Inner)	London Ambulance Service Metropolitan Police	2/2
23 Sep 2013	Sally King 2013-0196 · Tom Osborne The provided concerns text is too truncated to identify specific safety issues.	South East Milton Keynes	Care Quality Commission Milton Keynes General Hospital	0/2