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.
Reports
| Date | Report | Responses identified |
|---|---|---|
| 6 Dec 2024 |
David Stables
2024-0676 · Marilyn Whittle
There were no recorded mental health or medication reviews for a patient over almost four years, raising concerns about whether these essential …
|
1/1 |
| 6 Dec 2024 |
Michael Thompson
2024-0674 · Louise Hunt
A significant surgical complication was not recorded in the operation note, meaning other staff were unaware. Furthermore, the official investigation failed to …
|
1/1 |
| 4 Dec 2024 |
Dean Ford
2024-0673 · Nadia Persaud
Mental health teams failed to perform holistic suicide risk formulations per NICE guidelines, with a senior clinician showing a simplistic assessment approach. …
|
1/1 |
| 4 Dec 2024 |
Kayleigh Melhuish
2024-0672 · M.E. Voisin
HMP Eastwood Park staff lack mandatory training on neurodiversity, ACCT procedures, and constant supervision. Healthcare staff also show deficiencies in ACCT review …
|
3/4 |
| 5 Dec 2024 |
Mazeedat Adeoye
2024-0671 · Graeme Irvine
The National Police Air Service discounted a critical heat signature during a search. London Borough of Newham's child services demonstrated unprofessional, hostile …
|
4/4 |
| 5 Dec 2024 |
William Lardner
2024-0670 · Rachael Griffin
Limited public transport and expensive drop-off charges at Bournemouth Airport force passengers to walk along dangerous, unpaved, high-speed roads. This creates significant …
|
2/2 |
| 4 Dec 2024 |
Patricia Curtis
2024-0669 · Elizabeth Gray
Non-uniform hospital discharge notes across Trusts risk critical patient information being unavailable during transfers. This can cause dangerous delays in providing life-saving …
|
2/2 |
| 3 Dec 2024 |
Mnayea Al Basman
2024-0668 · Ian Potter
Insufficient professional curiosity, "falsely reassuring" notes, and failure to escalate a patient's decline by clinicians led to a lack of consultant involvement …
|
1/1 |
| 25 Nov 2024 |
Jonathon Lawlor
2024-0667 · Catherine Wood
Due to severe staff shortages, keywork sessions for prisoners were drastically reduced, potentially increasing risks for those in custody, despite guidance recommending …
|
1/1 |
| 3 Dec 2024 |
Gary Dunn
2024-0666 · Lorraine Harris
Inadequate road signage at a busy roundabout, especially for lane usage and alternative pedestrian/cyclist routes, makes navigation difficult for unfamiliar drivers and …
|
1/2 |
| 29 Nov 2024 |
Charlie Owen
2024-0665 · Robert Simpson
The army's vulnerability risk management process fails to ensure 'check-ins' for high-risk soldiers, and suicide prevention training for welfare officers is not …
|
1/1 |
| 28 Mar 2024 |
Daniela Pani
2024-0664 · Robert Simpson
Unimplemented safety measures at a train station, including lack of Samaritan signs and low fencing, were identified. Additionally, mental health staff lacked …
|
2/3 |
| 2 Dec 2024 |
Norma Tellam
2024-0663 · Stephen Covell
Decisions around patient transfers between hospitals failed to prioritise continuity of clinical care. This led to a patient with post-operative complications being …
|
1/3 |
| 3 Sep 2024 |
Samsam Ateye
2024-0662 · Anton Van Dellen
The existing policy for COVID-19 testing prior to cardiac surgery requires review to ensure patient safety and prevent future deaths.
|
1/1 |
| 2 Dec 2024 |
Gloria Linton
2024-0661 · Oliver Longstaff
Carers repeatedly failed to use a mandated transfer aid (Rotanda), contravening the care plan and previous instructions. This non-compliance resulted in improper …
|
1/1 |
| 2 Dec 2024 |
Elton Deutekom
2024-0660 · Fiona Wilcox
A newly qualified midwife was distracted by administrative tasks, missing critical CTG changes. The obstetric registrar failed to identify acute hypoxic injury …
|
2/3 |
| 2 Dec 2024 |
Junior Powell
2024-0659 · Fiona Wilcox
Significant hospital delays in patient review and admission, caused by staff shortages and social care discharge bottlenecks, led to a critical delay …
|
0/1 |
| 2 Dec 2024 |
Alfie Hinton
2024-0658 · Charlotte Keighley
Inadequate assessment and communication of maternal risks led to delays in monitoring and expediting delivery. Poor communication and absence of policy between …
|
1/1 |
| 2 Dec 2024 |
Keith Foord
2024-0657 · Rachel Redman
Aortic dissection requiring emergency surgery and inter-facility transfer is insufficiently categorised, leading to delays. Reclassifying it as Category 1 is necessary to …
|
1/1 |
| 28 Nov 2024 |
Oliver Billings
2024-0656 · Luisa Nicholson
A pharmacy issued a subsequent prescription without confirming the cancellation of a previous one, and rapid dispatch prevented error detection. The patient …
|
3/3 |