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 318 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
23 Sep 2013	Yvonne Sydney Annie Perry 2013-0195 · Tom Osborne A lack of robust processes for tracking radiology reports led to critical delays in patient care. Additionally, GPs in the intermediate care …	South East Milton Keynes	Care Quality Commission Milton Keynes General Hospital	0/2
19 Sep 2013	Alfie-Scott Harris, Mohammed Mohinudeen and Caitlyn Bennet 2013-0347 · Sarah Ormond-Walshe Neonatal units may lack awareness of cardiac tamponade as a complication of TPN feeding and are not sharing best practices or lessons …	West Midlands Birmingham & Solihull	SENAT, Birmingham Woman’s Hospital and …	0/1
19 Sep 2013	Daniel Onley 2013-0208 · Tom Osborne Insufficient arrangements were in place to support the patient in taking anti-convulsant medication, and there was a failure to manage associated risks.	South West Gloucestershire	Camp Village Trust Care Quality Commission Gloucestershire Social Services	1/3
17 Sep 2013	Luke Lyons 2013-0203 · Dr Elizabeth Earland The coroner identifies that water egress across a road washes away salt gritting, and an installed drain to mitigate this black ice …	South West Exeter & Greater Devon	Devon County Council	1/1
16 Sep 2013	Reggie John 2013-0202 · G U Williams Poor communication and lack of written records between prisons compromised a high-risk prisoner's care. Failures included inadequate review processes and a nurse …	West Midlands Worcestershire	HMP Bristol HMP Hewell Worcestershire Health and Care NHS …	2/3
16 Sep 2013	Rachael Dallison 2013-0205 · Andrew Haigh The provided concerns text is too truncated to identify specific safety issues.	West Midlands Staffordshire (South)	Commissioner for Transport Staffordshire County Council	0/2
12 Dec 2013	Felix Cembrowicz 2013-0204 · Terence Moore The electronic patient record system failed to migrate complete histories for discharged mental health patients, leaving current staff unaware of crucial past …	South West Avon	Avon and Wiltshire Mental Health …	1/1
10 Sep 2013	David Douglas Hackman 2013-0346 · David Ridley After a previous overdose attempt, a patient undergoing mental health assessment in a hospital unit was able to leave unnoticed, leading to …	South West Wiltshire & Swindon	NHS England	0/1
9 Sep 2013	John Michael Bailey 2013-0198 · Jullian Fox The coroner identifies a lack of patient awareness regarding symptoms of Amiodarone toxicity and the absence of clear protocols for informing patients …	Yorkshire and the Humber South Yorkshire (West)	Department of Health and Social …	0/1
6 Sep 2013	Peter Pattinson 2013-0250 · Derek Winter Care home staff failed to act on family requests for bed rail use and repairs, did not conduct risk assessments, and maintained …	North East Sunderland	European Care group	1/1
5 Sep 2013	Labhuden Amarshi Vaghadia 2013-0201 · Catherine Mason A community nurse administered anticoagulant despite patient bleeding, failed to share critical information with other professionals, and demonstrated a lack of professional …	East Midlands Leicester City & South Leicestershire	Leicestershire Partnership NHS Trust	1/1
4 Sep 2013	Karen Sutton 2013-0223 · Lydia Brown Hospital departments failed to share patient admission information, leading to discharge without prophylactic medication and inadequate follow-up arrangements due to a lack …	East Midlands Leicester City & South Leicestershire	University Hospitals Leicester NHS Trust	1/1
30 Aug 2013	Jessica Ashton-Pyatt 2013-0200 · ARW Forrest The emergency response was uncoordinated, lacked consultant leadership, and critical equipment like the defibrillator was uncharged with missing pads, compromising immediate patient …	East Midlands South Lincolnshire	United Lincolnshire Hospitals NHS Trust	0/1
30 Aug 2013	Jack William Payton 2013-0220 · Michael Rose Control room staff's judgement and handling of the matter were negatively affected by excessive working hours and heavy caseloads, raising concerns about …	South West West Somerset	Avon and Somerset Constabulary	1/1
30 Aug 2013	May Gibson 2013-0199 · Christopher Dorries The report identifies failures in obtaining and accounting for a community care assessment, performing pre-assessments, developing adequate care plans, conducting risk assessments, …	Yorkshire and the Humber South Yorkshire (West)	LNT Software Helios 47 Herries Lodge Care Home	0/2
29 Aug 2013	Martin Leslie Brown 2013-0209 · Tom Osborne The certificate for a road resurfacing product (Milepave) contained ambiguous wording regarding speed limit applicability and road types, risking its inappropriate use …	South West Gloucestershire	British Board of Agreement Fletcher's Solicitors Gloucestershire Constabulary Gloucestershire Highways	1/7
28 Aug 2013	Dorothy Townley 2013-0219 · Joanne Kearsley Significant communication breakdowns between District Nurses and the GP, inadequate burns treatment knowledge and training, and unclear procedures for urgent blood tests …	North West Manchester (South)	Royal College of General Practitioners Royal College of Nursing	1/2
28 Aug 2013	Terence O’Connell 2013-0218 · Louise Hunt A severe communication breakdown between the care home, district nurses, and out-of-hours GP led to the patient not being seen, alongside a …	Wales Bridgend, Glamorgan Valleys & Powys	ABMU Health Board Grove Medical Centre Monkstone House Care Home	2/3
27 Aug 2013	Muniza Mehrban 2013-0216 · Michael Singleton This marks the fourth death in three years at the multi-storey car park due to individuals jumping, indicating an urgent need for …	North West Blackburn, Hyndburn & Ribble Valley	Jesta Capital Corporation	0/1
23 Aug 2013	Luna Lesko 2013-0214 · Andrew Harris Delays in essential foetal monitoring and performing a Category 2 Caesarean section, coupled with insufficient out-of-hours theatre capacity, create a real risk …	London London (Inner South)	NHS Lewisham Commissioning Group University Hospital Lewisham	1/2