Samsam Ateye
AI-generated concerns summaryThe coroner raised concerns regarding the policy for Covid-19 testing before cardiac surgery, specifically valve replacement procedures.
Addressed to: NHS England
Source · Prevention of Future Deaths
Prevention of Future Deaths Reports
Browse 6,470 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
Gloria Linton
AI-generated concerns summaryThe coroner noted that carers did not routinely use a Rotanda for transfers as required by the care plan, and this omission led to the patient being incorrectly positioned on a commode.
Addressed to: Lifeway Care Ltd
Elton Deutekom
AI-generated concerns summaryThe coroner identified issues at Chelsea and Westminster Hospital regarding the timely referral of neonatal deaths to the coroner, compliance with the duty of candour, and midwifery record-keeping practices. Further concerns included labour ward understaffing, insufficient supervision for newly qualified midwives, and the lack of a regular CTG review system.
Addressed to: Chelsea and Westminster NHS Foundation Trust; National Medical Examiner; NHS England
Junior Powell
AI-generated concerns summaryDelays in patient discharge due to a lack of suitable community social care are causing hospital congestion, which in turn delays urgent medical assessment and diagnosis, increasing the likelihood of death.
Addressed to: Department of Health and Social Care
Alfie Hinton
AI-generated concerns summaryThe coroner identified insufficient evidence of maternal risk assessment and communication of high-risk factors to staff, contributing to delays in monitoring and delivery. Concerns were also raised about communication between consultant teams and the absence of a policy for managing time-critical situations during labour.
Addressed to: Airedale NHS Foundation Trust
Keith Foord
AI-generated concerns summaryThe coroner noted that an ambulance service incorrectly categorised a patient requiring critical emergency cardiac surgery as category 2 instead of category 1, which was deemed inappropriate by all clinical, paramedic, and expert witnesses.
Addressed to: NHS England
Oliver Billings
AI-generated concerns summaryThe coroner noted insufficient checks on prescription status before issuing subsequent prescriptions, with swift dispatch hindering error detection. There were also concerns about the patient's burden to resolve errors when the pharmacy was unreachable.
Addressed to: Clare House Surgery; Pharmacy2U Limited; Royal Pharmaceutical Society
Elan Adams
AI-generated concerns summaryThe coroner raised concerns about poor phone line quality impacting emergency calls from resident bedrooms, unclear communication from nursing staff to emergency services, and a faulty resident call bell system that created uncertainty about staff attendance.
Addressed to: Abbey Healthcare
Jay Whiting
AI-generated concerns summaryThe coroner noted concerns regarding mature trees lining Embankment Road, Plymouth, as their close proximity to the carriageway creates a collision risk for vehicles leaving the road and obstructs pedestrian movement on the pavement.
Addressed to: Plymouth City Council
Kenneth King
AI-generated concerns summaryThe coroner raised concerns regarding the lack of a formal structure for physiological observations on community patients, which relies on subjective clinical judgment. Delays were also noted in implementing a new training programme and a policy for bank staff qualifications.
Addressed to: Norfolk Community Health & Care NHS Trust
Colin Wiles
AI-generated concerns summaryThe coroner identified the absence of a Vulnerable Adult Risk Management meeting and unclear advice for emergency service callers to call back. Concerns were also raised about excessive ambulance handover delays at Hull Royal Infirmary due to patient criteria and capacity issues.
Addressed to: East Riding of Yorkshire Council; Hull University Teaching Hospital; NHS England
Amy Butcher
AI-generated concerns summaryThe coroner identified a muddled and unclear system for prescribing medication to mental health patients in crisis, which lacked a single point of contact or decision maker. This required individuals to navigate multiple services, compounded by differing prescription policies among providers.
Addressed to: Department of Health and Social Care; Norfolk and Suffolk NHS Foundation Trust
Nicolette McCarthy
AI-generated concerns summaryThe coroner raised concerns that the NHS smoke-free policy may increase risks of self-harm and suicide for mental health patients by contributing to poorly supervised smoking areas. This policy creates challenges for staff in balancing compliance with patient autonomy and safety needs.
Addressed to: Department of Health and Social Care; National Institute for Health and Care Excellence; NHS England
Dean Bray
AI-generated concerns summaryThe coroner noted staff could not make direct 999 calls from the seclusion room observation area, and paramedics faced delays accessing the patient due to an unknown immediate access route to the ward.
Addressed to: Southern Health Foundation Trust
Jon-Paul Prigent
AI-generated concerns summaryConcerns relate to the lack of periodic independent testing and mandatory safety features, such as anti-decoupling devices, for agricultural tractors and trailers on public roads, noting current regulations are outdated for modern vehicle use.
Addressed to: Department for Transport; Driving Standards Agency; Agricultural Engineers Association; British Agricultural and Garden Machinery Association; Health and Safety Executive; National Farmers Union
Susan Paley
AI-generated concerns summaryThe coroner noted that a resident with limited mobility was left without an accessible call bell, and care staff at Hilltop Court lacked a checklist to ensure specific resident aids were in place.
Addressed to: Harbour Healthcare Ltd
Emma Sanders
AI-generated concerns summaryThe patient's Frequent Attender Care Plan was not shared with ambulance services or accessible promptly within the hospital, meaning staff monitoring the patient in the cohorting area did not have access to critical information regarding her history of self-harm.
Addressed to: NHS Dorset; NHS England
Jaipreet Panesar
AI-generated concerns summaryThe coroner noted that no care co-ordinator was provided to the patient after hospital discharge. Additionally, different clinical systems (RiO and BTT) were unable to access each other's clinical notes.
Addressed to: Oxford Health NHS Foundation Trust
Margaret Feeney
AI-generated concerns summaryThe coroner noted a lack of measures at Macklin Street Surgery and Daynight pharmacy to prevent excess medication prescriptions for at-risk patients during longer bank holiday periods, increasing overdose risk.
Addressed to: Daynight Pharmacy; Department of Health and Social Care; Macklin Street Surgery; NHS Derby and Derbyshire Integrated Care Board
Muhammad & Naemat Esmael
AI-generated concerns summaryThe coroner raised concerns that current Welsh legislation for rented properties, requiring only two smoke alarms, may not adequately protect against fires in individual rooms, posing a continuing risk to life. Additionally, items were removed from the fire scene before a full expert inspection, which hindered the investigation into the …
Addressed to: Mid and West Wales Fire and Rescue Service; Welsh Government