John Hoare
AI-generated concerns summaryThe coroner noted inadequate provision of basic medical attention regarding lithium prescribing and dispensing, which resulted in the patient being sectioned.
Addressed to: Low Moor Medical Practice
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
Barry Lall
AI-generated concerns summaryThe coroner raises concerns about the level of detail published on the GDC website regarding allegations against dental practitioners before proceedings are concluded, noting a potential detrimental effect on individuals' mental health.
Addressed to: General Dental Council
Jacqueline Carrey
AI-generated concerns summaryThe coroner identified a lack of clear indication on the patient's medical record regarding potential medication abuse risk, which was not flagged to staff before discharge. This raises concerns about the hospital's procedures for managing medication and patient records.
Addressed to: Milton Keynes University Hospital
Federica Cavenati
AI-generated concerns summaryThe coroner noted the absence of intravenous antidepressant medication in the United Kingdom for patients unable to take oral medication, despite its availability in Europe.
Addressed to: Medicines and Healthcare products Regulatory Agency
Bronwen Morgan
AI-generated concerns summaryThe coroner identified concerns regarding the accessibility of websites that facilitate or promote self-harm and suicide, providing vulnerable individuals with information and means. Consideration should be given to actions to remove, limit, or mitigate such access.
Addressed to: Department for Digital, Culture, Media and Sport; Ofcom; Welsh Health Minister; Welsh Health Minister
Iain Farrell
AI-generated concerns summaryThe coroner raised concerns regarding the risks of lone guiding in coasteering and the need for clear guidance on guide-to-participant ratios. There were also concerns about the guide not having immediate access to communication for emergencies, and the lack of assessment for participant swimming ability and physical fitness during booking.
Addressed to: National Coasteering Charter
Frederick Powell
AI-generated concerns summaryThe coroner suggested a review to reconsider the replacement of internal glass doors in properties, noting that many in the stock still retained them, despite not breaching current building regulations.
Addressed to: Acis Housing
Tracy Gambrill
AI-generated concerns summaryThe coroner noted concerns that surgical incisions were excessively deep and that intra-operative measurement of incision length is not current expected practice during this type of neurosurgical procedure.
Addressed to: NHS England; General Medical Council; Royal College of Surgeons of England; Society of British Neurological Surgeons
Jennifer Campbell
AI-generated concerns summaryThe coroner raised concerns regarding the absence of a formal investigation into a lost ERCP referral, which prevented learning and improvement. There was also a lack of audits for other lost referrals and delays in fully implementing electronic referral systems, posing patient risks.
Addressed to: Betsi Cadwaladr University Health Board
Peter Carr
AI-generated concerns summaryThe coroner identified that patients with acute, severe skin conditions may not receive consultant dermatology input and biopsy within 24 hours, or ongoing consultant oversight during their inpatient stay.
Addressed to: Department of Health and Social Care
Jonathan McCarthy
AI-generated concerns summaryThe coroner raises concerns about prison policies and procedures for verifying pre-existing community hospital appointments, assessing their clinical urgency, and determining a prisoner's fitness for transfer.
Addressed to: Ministry of Justice; NHS England; Practice Plus Group; Serco
Jill Brice
AI-generated concerns summaryThe coroner requested reassurance that care residents would be reminded to keep their fire safety pendants close to them at all times, following a recommendation in a fire safety report.
Addressed to: Care Quality Commission; Department for Housing
Valerie Simmons
AI-generated concerns summaryThe coroner noted that observations should be undertaken and recorded following a change in a patient's presentation. Further training was also identified as beneficial regarding the risks of hypovolaemia in anticoagulated patients.
Addressed to: Community Nurse Locality Team Lead
Karlton Donaghey
AI-generated concerns summaryThe coroner noted that helium balloons linked to a death are freely available without restriction or warnings, and parents or supervisors of children are not fully aware of the risks they pose.
Addressed to: Product Safety and Standards
Norma Kyte
AI-generated concerns summarySensory mats used by bedsides were identified as being too small to reliably detect when a patient got out of bed, potentially leading to staff being unaware of movement or falls. There were also concerns that the mats might not be used according to manufacturer instructions.
Addressed to: Broomcroft House Nursing Home; BUPA
Thomas Doyle
AI-generated concerns summaryThe coroner identified particularly poor standards of clinical records, impeding investigation into whether infection was considered. There was also a failure to commence a diagnostic pathway for sepsis upon admission, contrary to local policy and national guidance.
Addressed to: Barking, Havering and Redbridge University Trust; Department of Health and Social Care
Myra Maxfield
AI-generated concerns summaryThe coroner noted the Tissue Viability Team at Royal Stoke University Hospital is unavailable during weekends, causing significant delays for patients needing assessment for pressure ulcers. These delays were identified as potentially contributing to patient deaths.
Addressed to: NHS England; University Hospital’s of North Midlands
Tyler Ryan
AI-generated concerns summaryThe coroner identified a chronic shortage of Paediatric Pathologists causing delays in reports, which postpones genetic testing for surviving siblings. There are also concerns regarding the underuse of molecular autopsy and the need to revise the SUDIC Protocol.
Addressed to: Department of Health and Social Care; NHS England; General Medical Council; Royal College of Pathologists
Kirsty Hendry
AI-generated concerns summaryLow awareness among primary care health professionals regarding key symptoms of a burst aneurysm can delay appropriate referrals for diagnostic scans. Improved understanding is needed for early identification and treatment.
Addressed to: NHS England
Wayne Milne
AI-generated concerns summaryThe practice had an inconsistent 999 calling procedure where nursing staff were not required to call for life-threatening conditions, leading to delayed urgent medical assistance. There was also a lack of awareness about Dissecting Aortic Aneurysm and no action taken by the practice following these events.
Addressed to: Rocky Lane Medical Centre