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 319 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
23 Aug 2013	Jill Sinson 2013-0221 · Melanie Williamson The GP failed to adequately monitor the deceased, prescribed large quantities of unsupervised medication despite a self-harm history, and staff neglected to …	Yorkshire and the Humber West Yorkshire (East)	Beeston Health Centre	0/1
21 Aug 2013	John Walker 2013-0213 · Christopher Wilkinson Insufficient risk care planning, lack of rationale for decreasing observation levels despite deteriorating mental state, and delays in reporting missing patients raised …	South East West Sussex	Sussex Partnership NHS Trust	1/1
20 Aug 2013	Ann Margaret Spearing 2013-0217 · T G Moore Despite clear malnutrition and learning difficulties, the deceased was repeatedly assessed by mental health, hospital, and eating disorder services, yet consistently misdiagnosed …	South West Avon	Chair	1/1
20 Aug 2013	Mohammed Chaudhury 2013-0193 · Andrew Harris The patient developed severe infected pressure sores due to the prolonged absence of an air mattress and insufficient turning, directly caused by …	London London (Inner South)	Care Quality Commission King’s College Hospitals NHS Foundation …	0/2
20 Aug 2013	Nicola Matthews 2013-0192 · Dr R N Palmer Incomplete documentation and unclear, undocumented follow-up arrangements for a high-risk patient discharged from inpatient care led to staff confusion and potential for …	London London (South)	South London and Maudsley NHS …	0/1
16 Aug 2013	Sadie Ann Jane McGrady 2013-0189 · John Gittins Substandard repairs to a Category D insurance write-off vehicle compromised its structural integrity, increasing injury risk in a collision, with no independent …	Wales North Wales (East & Central)	Driver and Vehicle Licensing Agency Association of British Insurers Vehicle and Operator Services Agency	2/3
16 Aug 2013	Keward Guy Domonic Harding 2013-0190 · Sheriff Payne An urgent mental health assessment was significantly delayed for over two weeks, potentially preventing detection of a decline in physical health that …	South West Dorset	Community Mental Health Team	0/1
15 Aug 2013	Ronald Ellwood 2013-0222 · Andrew Haigh The provided concerns text is too truncated to identify specific safety issues.	West Midlands Staffordshire (South)	Queen’s Hospital	1/1
14 Aug 2013	Jordan Buckton 2013-0187 · Sheriff Payne Prison staff lacked awareness of a prisoner's self-harm history due to information sharing failures. Additionally, there was inadequate follow-up after prescribing anti-depressants …	South West Dorset	Dorset Healthcare University NHS Foundation … National Offender Management Service	0/2
13 Aug 2013	Vera Lillian Steel 2013-0185 · Michael Burgess A frail, bedbound resident fatally burned herself while smoking. Care homes should be encouraged to provide fire-protective aprons or smocks to residents …	South East Surrey	Care Quality Commission South East England Fire and …	0/2
9 Aug 2013	Ronald Sherlock 2013-0181 · William Armstrong Older prisoners lacked appropriate access to speech and language therapists to assess and manage swallowing difficulties, including recommendations for diet and fluid …	East of England Norfolk	Serco	0/1
8 Aug 2013	Matthew Thomas Hamilton 2013-0180 · D L I Roberts A narrow footpath lacked a barrier, allowing children to emerge suddenly into traffic, compounded by restricted vision from a fence and shrubbery.	North West Cumbria (North & West)	Cumbria County Council	0/1
8 Aug 2013	Dimitar Shtarbov 2013-0178 · Alexander R W Forrest Seasonal agricultural workers lacked awareness of and access to GP and emergency services in the UK. Many also self-medicated with prescription-only medicines …	East Midlands South Lincolnshire	East Lincolnshire Clinical Commissioning Group South Lincolnshire Clinical Commissioning Group	0/2
7 Aug 2013	Jean Miller 2013-0191 · Alison Mutch District nurses failed to baseline a patient's wound, did not involve tissue viability specialists, and did not routinely take temperatures, as they …	North West Manchester (West)	Pennine Care Trust	0/1
7 Aug 2013	Ethel Smith Leese 2013-0184 · Andrew Haigh Chaotic address verification procedures by the hospital post-discharge led to significant issues with the monitoring of Mrs. Leese's warfarin levels after her …	West Midlands South Staffordshire	Stafford Hospital	0/1
6 Aug 2013	Lucy Hannah Rose Bailey 2013-0176 · Robert Chapman Concerns were raised regarding the adherence to or adequacy of guidelines for managing dystocia, which was identified as a known hazard.	East Midlands Rutland & North Leicestershire	JRCALC East Midlands Ambulance Service South Central Ambulance Service	1/3
5 Aug 2013	Joseph Burrell 2013-0194 · John Taylor The road junction lacked adequate pedestrian safety features, including no clear view of traffic lights, no 'red man/green man' signals, and no …	London London (North)	Harrow Council Traffic and Harrows Network Management …	1/2
5 Aug 2013	Alan Smith 2013-0173 · John Gittins A co-worker lacked specific training for working at height, and generic risk assessment forms and method statements were not routinely used by …	Wales North Wales (East & Central)	Carrington Doors	0/1
1 Aug 2013	Annie Rose Gibson 2013-0171 · David Hinchcliff The coroner raises concerns about a lack of clarity in Saga Homecare's procedures, specifically regarding the recording and communication of observations after …	Yorkshire and the Humber West Yorkshire (East)	Saga Homecare	0/1
1 Aug 2013	Michael James Thornton 2013-0170 · Michael Rose Vehicles leaving the carriageway and landing in a rhynne leads to death by drowning; however, retaining barriers may be too costly given …	South West West Somerset	Somerset County Council Taunton Couthy Hall County Surveyor	0/3