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 48 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
16 Dec 2024	Anne Leake 2024-0696 · Duncan Ritchie Fragmented medical record systems across hospital teams resulted in a critical multi-disciplinary team decision being overlooked, with current interim solutions still vulnerable …	West Midlands Staffordshire and Stoke-on-Trent	University Hospitals of North Midlands …	1/1
18 Dec 2024	Eleanor Aldred-Owen 2024-0695 · Helen Rimmer The hospital's standard operating procedure for radiographers lacked provisions for escalating care or initiating urgent arrest calls when patients showed clear signs …	North West Liverpool and Wirral	NHS England	1/1
10 Dec 2024	Craig Spiby 2024-0694 · Timothy Brennand Care staff lacked consistent understanding and training on supervising a high-choking-risk resident, expressed low confidence in emergency first aid, and failed to …	North West Manchester West	Bolton Cares	1/1
22 Oct 2024	Richard Roe 2024-0693 · Simon Milburn A critical lack of a system to ensure routine CT scan reports are reviewed by clinicians, despite previous similar incidents, poses an …	East of England Cambridgeshire & Peterborough	NORTH WEST ANGLIA NHS FOUNDATION …	1/1
17 Dec 2024	Mary Whitlock 2024-0692 · Sonia Hayes A patient with opioid allergies was given morphine, highlighting a medication error. Concerns also included persistent ward understaffing and the absence of …	East of England Essex	Mid & South Essex NHS …	1/1
13 Dec 2024	Timothy De Boos 2024-0691 · Nigel Parsley A severe and persistent shortage of mental health inpatient beds, combined with a crisis team overriding the experienced mental health professional, family, …	East of England Suffolk	Department of Health and Social …	1/1
16 Dec 2024	Matthew Sheldrick 2024-0690 · Penelope Schofield Severe national shortages of mental health beds, especially for autistic and transgender patients, led to dangerously long A&E waits, where the environment …	South East West Sussex, Brighton and Hove	Department of Health and Social … NHS England	2/2
16 Dec 2024	Matthew Sheldrick 2024-0689 · Penelope Schofield Critical shortages of mental health inpatient beds, particularly for neurodiverse and transgender patients, led to dangerous A&E wait times and an unsuitable …	South East West Sussex, Brighton and Hove	Sussex ICB	1/1
13 Dec 2024	Laura-Jane Seaman 2024-0688 · Sonia Hayes Critical failures in medical record-keeping, delayed patient escalation, non-compliance with major haemorrhage protocols, and misidentification of maternal collapse contributed to the death, …	East of England Essex	Mid & South Essex NHS … Royal College of Obstetricians and …	2/2
13 Dec 2024	Susan Evans 2024-0687 · Sally Olsen Critical failures in adhering to the hospital's post-operative care pathway for bariatric patients, including missing specialist reviews and unescalated pain, significantly contributed …	South East Hampshire, Portsmouth and Southampton	Portsmouth Hospital NHS Trust	1/1
24 Oct 2024	Alice Clark 2024-0686 · Roger Hatch Unsafe paramedic driving standards were not appropriately addressed due to the lack of a formal complaint procedure and inadequate independent assessment of …	South East North West Kent	South East Coast Ambulance Service	1/1
12 Dec 2024	Thomas Burroughs 2024-0685 · Sonia Hayes A split Hickman Catheter, posing a significant infection risk, was not removed promptly despite advice and was not reported via the Trust's …	East of England Essex	Mid & South Essex NHS …	1/1
11 Dec 2024	Nonie Atshiki 2024-0684 · Mary Hassell Hostel night staff lacked essential first aid, CPR, and naloxone training, and the facility did not have a defibrillator, compromising emergency response …	London Inner North London	St Mungo’s	1/1
11 Dec 2024	Fehim Ahmet 2024-0683 · Mary Hassell Estate agents lack industry standards or guidance for informing tenants about property hazards, such as unsafe accessible flat roofs, and failed to …	London Inner North London	National Trading Standards Network Agencies Estate Agents	3/2
10 Dec 2024	Karen Day 2024-0682 · Emma Mather The GP practice failed to follow lower limb wound care frameworks, escalate concerns, or support patient self-management. Furthermore, it lacked adequate systems …	Yorkshire and the Humber West Yorkshire (East)	Meanwood Group Practice	1/1
10 Dec 2024	Karen Dack 2024-0681 · Dianne Hocking Repeated last-minute surgery cancellations are occurring due to insufficient theatre capacity. Despite prioritization reviews, a lack of theatre expansion means this systemic …	East Midlands Leicester City and South Leicestershire	Department of Health and Social …	1/1
10 Dec 2024	Charles Devos 2024-0680 · Guy Davies Extreme operational pressure on ambulance services, exacerbated by inadequate social care, causes excessive 999 call delays and unallocated calls. This forces call …	South West Cornwall & the Isles of Scilly	Department of Health and Social …	1/1
10 Dec 2024	Peter McCarthy 2024-0679 · Caroline Topping Care staff lacked protocols to prevent administering anticoagulant medication to clients who had fallen, due to an inability to identify contraindications without …	South East Surrey	Care4U Healthcare	0/1
9 Dec 2024	Luke Albiston O’Donnell 2024-0678 · Anita Bhardwaj The public is largely unaware of the life-threatening fire risks posed by lithium-ion batteries from electronic devices stored in homes. There is …	North West Liverpool and Wirral	National Fire Chief’s Council Office of Product Safety Standards	2/2
6 Dec 2024	Champagauri and Dipak Bhatt 2024-0677 · Peter Straker Fires are caused by moisture ingress into condensate pumps. There's inadequate data sharing and analysis for white goods fires, poor manufacturing standards …	London North London	Association of Manufacturers of Domestic … British Standards Institute Hotpoint UK Appliances Limited National Fire Chief’s Council	8/7