Prevention of Future Deaths Reports

Judiciary

Browse 6,327 coroners' Regulation 28 reports by year, region, organisation, category, or keyword.

Data sourced from judiciary.uk under the Open Government Licence.

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6,327 reports · Page 303 of 317
Showing 20 at a time
Date Report Region / area Addressee(s) Status Responses
12 Mar 2014 Stephen Tilbury
2014-0109 · Nadia Persuad
Excessive vehicle speed in a residential area, despite an existing trief curb, poses a significant risk as the curb can deflect speeding …
London
London (East)
 London Borough of Havering Historic (No Identified Response) 0/1
12 Mar 2014 Wendy Brown
2014-0113 · David Ridley
Significant delays in implementing care packages and providing respite support for vulnerable carers, compounded by inadequate signposting of adult care services, complicated …
South West
Wiltshire & Swindon
 Swindon Borough Council All Responded 1/1
12 Mar 2014 Andrew Hall
2014-0122 · Anthony Eastwood
Inadequate communication and documentation of mental health risks, failure to administer prescribed medication, and insufficient patient observation within the prison healthcare unit …
North East
Teesside
 HM Prison and Probation Service North Tees and Hartlepool NHS … Tees, Esk and Wear Valleys … Partially Responded 1/3
11 Mar 2014 Christopher Shapley
2014-0121 · Christopher Woolley
Critical medical and self-harm risk information from police custody failed to transfer securely to the prison via the PER form, leading to …
Wales
Cardiff & the Vale of Glamorgan
 HM Prison Cardiff Home Office Historic (No Identified Response) 0/2
11 Mar 2014 Afifa Qaisar
2014-0107 · John Pollard
Critical issues included inaccurate drug administration records, missing emergency equipment, delays in urgent platelet transfusions, and a failure to properly monitor fluid …
North West
Manchester (South)
 Tameside Hospital NHS Foundation Trust Historic (No Identified Response) 0/1
11 Mar 2014 Saleh Ali Dalie
2014-0108 · Louise Hunt
This residential road has a history of multiple incidents and two fatalities, yet requested road calming, parking restrictions, and pedestrian crossing measures …
West Midlands
Birmingham & Solihull
 Birmingham City Council West Midlands Police Partially Responded 1/2
11 Mar 2014 Teresa Lonergan
2014-0110 · Andrew Harris
The patient accumulated a dangerous hoard of prescribed controlled drugs due to a lack of monitoring by healthcare professionals, enabling a fatal …
London
London (Inner South)
 Eltham Park Surgery Historic (No Identified Response) 0/1
11 Mar 2014 Lorna Cullen
2014-0105 · Allison Summers
The coroner raised concerns about long-term liaison psychiatry nurse staffing levels covering hospital emergency departments, after evidence indicated patients needing mental health …
South East
Mid Kent & Medway
 NHS Medway Clinical Commissioning Group NHS Swale Clinical Commissioning Group Historic (No Identified Response) 0/2
10 Mar 2014 Craig Marren
2014-0106 · Kevin McLoughlin
Trees and foliage at a blind left-hand bend significantly impede driver visibility, creating a dangerous road hazard that requires cutting back.
Yorkshire and the Humber
West Yorkshire (East)
 Tyersal Farm All Responded 1/1
10 Mar 2014 Derrick Rivers
2014-0104 · Lisa Hashmi
The care home had an inadequate, unspecific drugs administration protocol and lacked audit processes, with management unaware of non-compliance. Regulatory bodies also …
North West
Manchester (North)
 Care Quality Commission Passmonds Care Home Rochdale Metropolitan Borough Council Historic (No Identified Response) 0/3
6 Mar 2014 Natasha Raghoo
2014-0100 · David Skipp
The coroner identified concerns regarding staff training in cardiopulmonary resuscitation and defibrillator use, sporadic physical observations, the lack of routine ECGs for …
South East
West Sussex
 Partnerships in Care South London and Maudsley NHS … Partially Responded 1/2
5 Mar 2014 John Fox
2014-0098 · Fiona Wilcox
Reduced physiotherapy services on bank holidays and weekends increase the risk of post-operative complications for vulnerable patients.
London
: London Inner (West)
 St George’s Hospital Historic (No Identified Response) 0/1
5 Mar 2014 Stephen Ellis
2014-0102 · John Pollard
A lack of warfarin home management kits for high-risk post-heart surgery patients leads to reliance on less efficient hospital monitoring.
North West
Manchester (South)
 Department of Health and Social … Historic (No Identified Response) 0/1
5 Mar 2014 Barry Dillion
2014-0099 · Michael Singleton
Insufficient resources are available to provide a comprehensive Speech and Language Therapy service at the hospital, potentially impacting patient care.
North West
Blackburn, Hyndburn & Ribble Valley
 East Lancashire Healthcare NHS Trust Historic (No Identified Response) 0/1
5 Mar 2014 Nellie Travis
2014-0101 · John Pollard
The hospital's Falls Risk Assessment tool is ineffective due to its subjective nature and inconsistent application by nursing staff, highlighting the need …
North West
Manchester (South)
 Tameside Hospital NHS Foundation Trust Historic (No Identified Response) 0/1
5 Mar 2014 Neil Carter
2014-0103 · Sean Cummings
There were repeated failures in basic nursing observations, chronic inadequate staffing and skill mix, and deliberate falsification of nursing records, compounded by …
London
London (West)
 Care Quality Commission Priory Group All Responded 2/2
4 Mar 2014 Anne-Marie Katherine Ellement
2014-0181 · Nicholas Rheinberg
The Armed Forces' victim support code lacks specific provision for serious sexual assault victims within the military, and staff managing suicide vulnerability …
South West
Wiltshire & Swindon
 Armed Forces Minister Provost Marshall (Army) Historic (No Identified Response) 0/2
4 Mar 2014 Ryan Pettengell
2014-0096 · Jacqueline Lake
Despite official closure and prior safety recommendations following multiple drownings, the site remains accessible to the public with damaged/missing signage and no …
East of England
Norfolk
 Borough Council of King’s Lynn … Norfolk County Council Norfolk Police Sibelco UK Ltd Historic (No Identified Response) 0/4
4 Mar 2014 Kathleen Border
2014-0095 · David Horsley
Inadequate and unclear signage for parking areas led to a delivery vehicle reversing outside a designated zone, causing a fatal collision.
South East
Portsmouth & South East Hampshire
 Northwood Square All Responded 1/1
3 Mar 2014 Kirabo Kiwanuka
2014-0088 · Andrew Harris
Significant disagreement among medical professionals on Neuroleptic Malignant Syndrome diagnosis and management, leading to unclear optimal care pathways and limited family involvement …
London
London (Inner South)
 Royal College of Physicians Royal College of Psychiatrists Historic (No Identified Response) 0/2
Stephen Tilbury Historic (No Identified Response)
12 Mar 2014 London 0/1 responses
Excessive vehicle speed in a residential area, despite an existing trief curb, poses a significant risk as the curb can deflect speeding vehicles onto …
London Borough of Havering
Wendy Brown All Responded
12 Mar 2014 South West 1/1 responses
Significant delays in implementing care packages and providing respite support for vulnerable carers, compounded by inadequate signposting of adult care services, complicated funding routes, …
Swindon Borough Council
Andrew Hall Partially Responded
12 Mar 2014 North East 1/3 responses
Inadequate communication and documentation of mental health risks, failure to administer prescribed medication, and insufficient patient observation within the prison healthcare unit were identified. …
HM Prison and Probation … North Tees and Hartlepool … Tees, Esk and Wear …
Christopher Shapley Historic (No Identified Response)
11 Mar 2014 Wales 0/2 responses
Critical medical and self-harm risk information from police custody failed to transfer securely to the prison via the PER form, leading to inadequate assessment …
HM Prison Cardiff Home Office
Afifa Qaisar Historic (No Identified Response)
11 Mar 2014 North West 0/1 responses
Critical issues included inaccurate drug administration records, missing emergency equipment, delays in urgent platelet transfusions, and a failure to properly monitor fluid balance, indicating …
Tameside Hospital NHS Foundation …
Saleh Ali Dalie Partially Responded
11 Mar 2014 West Midlands 1/2 responses
This residential road has a history of multiple incidents and two fatalities, yet requested road calming, parking restrictions, and pedestrian crossing measures have not …
Birmingham City Council West Midlands Police
Teresa Lonergan Historic (No Identified Response)
11 Mar 2014 London 0/1 responses
The patient accumulated a dangerous hoard of prescribed controlled drugs due to a lack of monitoring by healthcare professionals, enabling a fatal overdose.
Eltham Park Surgery
Lorna Cullen Historic (No Identified Response)
11 Mar 2014 South East 0/2 responses
The coroner raised concerns about long-term liaison psychiatry nurse staffing levels covering hospital emergency departments, after evidence indicated patients needing mental health assessments were …
NHS Medway Clinical Commissioning … NHS Swale Clinical Commissioning …
Craig Marren All Responded
10 Mar 2014 Yorkshire and the Humber 1/1 responses
Trees and foliage at a blind left-hand bend significantly impede driver visibility, creating a dangerous road hazard that requires cutting back.
Tyersal Farm
Derrick Rivers Historic (No Identified Response)
10 Mar 2014 North West 0/3 responses
The care home had an inadequate, unspecific drugs administration protocol and lacked audit processes, with management unaware of non-compliance. Regulatory bodies also failed to …
Care Quality Commission Passmonds Care Home Rochdale Metropolitan Borough Council
Natasha Raghoo Partially Responded
6 Mar 2014 South East 1/2 responses
The coroner identified concerns regarding staff training in cardiopulmonary resuscitation and defibrillator use, sporadic physical observations, the lack of routine ECGs for patients on …
Partnerships in Care South London and Maudsley …
John Fox Historic (No Identified Response)
5 Mar 2014 London 0/1 responses
Reduced physiotherapy services on bank holidays and weekends increase the risk of post-operative complications for vulnerable patients.
St George’s Hospital
Stephen Ellis Historic (No Identified Response)
5 Mar 2014 North West 0/1 responses
A lack of warfarin home management kits for high-risk post-heart surgery patients leads to reliance on less efficient hospital monitoring.
Department of Health and …
Barry Dillion Historic (No Identified Response)
5 Mar 2014 North West 0/1 responses
Insufficient resources are available to provide a comprehensive Speech and Language Therapy service at the hospital, potentially impacting patient care.
East Lancashire Healthcare NHS …
Nellie Travis Historic (No Identified Response)
5 Mar 2014 North West 0/1 responses
The hospital's Falls Risk Assessment tool is ineffective due to its subjective nature and inconsistent application by nursing staff, highlighting the need for a …
Tameside Hospital NHS Foundation …
Neil Carter All Responded
5 Mar 2014 London 2/2 responses
There were repeated failures in basic nursing observations, chronic inadequate staffing and skill mix, and deliberate falsification of nursing records, compounded by management's failure …
Care Quality Commission Priory Group
Anne-Marie Katherine Ellement Historic (No Identified Response)
4 Mar 2014 South West 0/2 responses
The Armed Forces' victim support code lacks specific provision for serious sexual assault victims within the military, and staff managing suicide vulnerability risk assessments …
Armed Forces Minister Provost Marshall (Army)
Ryan Pettengell Historic (No Identified Response)
4 Mar 2014 East of England 0/4 responses
Despite official closure and prior safety recommendations following multiple drownings, the site remains accessible to the public with damaged/missing signage and no implemented safety …
Borough Council of King’s … Norfolk County Council Norfolk Police
Kathleen Border All Responded
4 Mar 2014 South East 1/1 responses
Inadequate and unclear signage for parking areas led to a delivery vehicle reversing outside a designated zone, causing a fatal collision.
Northwood Square
Kirabo Kiwanuka Historic (No Identified Response)
3 Mar 2014 London 0/2 responses
Significant disagreement among medical professionals on Neuroleptic Malignant Syndrome diagnosis and management, leading to unclear optimal care pathways and limited family involvement for sectioned …
Royal College of Physicians Royal College of Psychiatrists