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 304 of 317
Showing 20 at a time
Date Report Region / area Addressee(s) Status Responses
3 Mar 2014 Lee MacPherson
2014-0097 · Elizabeth Pygott
Delayed police risk assessments and a lack of common understanding between escort and prison staff regarding critical handover documentation posed significant safety …
London
London (West)
 HMP Wormwood Scrubs Metropolitan Police National Offender Management Service Serco Historic (No Identified Response) 0/4
3 Mar 2014 Carl Morris
2014-0092 · Robert Chapman
North West
Cumbria (North & West)
 Professional Association of Diving Instructors All Responded 1/1
3 Mar 2014 Marco Lima De Araujo
2014-0093 · David Horsley
There is no formal protocol for reporting and coordinating rescue efforts during life-threatening incidents in Portsmouth Harbour.
South East
Portsmouth & South East Hampshire
 Queen’s Harbour Master Portsmouth All Responded 1/1
3 Mar 2014 Kevin Pearson
2014-0086 · Paul Kelly
The company potentially failed to ensure full compliance with health and safety guidance for drivers and verify their understanding of critical instructions …
Yorkshire and the Humber
North Lincolnshire & Grimsby
 John Somerscales Ltd Historic (No Identified Response) 0/1
3 Mar 2014 Margaret Easterfield
2014-0091 · Rachel Redman
A rare anastomotic leak following surgery, leading to the patient's death, raises concerns about a potential technical error by the surgeon.
South East
Kent (South East & Central)
 East Kent University Hospital Historic (No Identified Response) 0/1
28 Feb 2014 Nathan Douthwaite
2014-0084 · Andrew Tweddle
A rectal biopsy would likely have diagnosed Hirschsprung's disease, highlighting concerns about current diagnostic guidelines and the trust's practices in this regard.
North East
County Durham & Darlington
 County Durham and Darlington NHS … Department of Health and Social … National Institute for Health and … Partially Responded 1/3
28 Feb 2014 Peter Norman Nott
2014-0229 · Nicholas Graham
Care home staff failed to perform adequate neurological observations following a patient's fall, relying on simple visual checks despite prolonged immobility and …
South East
Oxfordshire
 Rush Court Nursing Home All Responded 1/1
28 Feb 2014 Richard White
2014-0085 · Crispin Oliver
Hope House lacked a formal, documented policy or protocol for medication administration, which was unknown to prescribers and not made available to …
North East
County Durham & Darlington
 700 Club All Responded 1/1
27 Feb 2014 Malcolm Potter
2014-0082 · Belinda Cheney
The pedestrian crossing's warning light system is inadequately positioned and not synchronized for multiple trains, creating a significant re-crossing risk on a …
East of England
Cambridgeshire (South & West)
 Network Rail Historic (No Identified Response) 0/1
27 Feb 2014 Victoria Meppen-Walter
2014-0083 · Lisa Hashmi
Concerns were raised regarding the easy online availability and regulation of chloroquine, along with the associated risks of its misuse.
North West
Manchester (North)
 Department of Health and Social … Medicines and Healthcare Products Regulatory … Historic (No Identified Response) 0/2
27 Feb 2014 Maureen Leaver
2014-0036 · Karen Henderson
Inadequate medical supervision and ineffective systems for investigating acutely ill elderly patients in a psychiatric ward were identified, alongside a lack of …
South East
West Sussex
 Sussex Partnership NHS Foundation Trust Historic (No Identified Response) 0/1
26 Feb 2014 Sidney Harvey
2014-0075 · Siobhan Kelly
Non-safety glass doors in rented properties, particularly where vulnerable individuals reside, pose a risk, and there is no clear system for their …
East Midlands
South Lincolnshire
 South Kesteven District Council Historic (No Identified Response) 0/1
26 Feb 2014 Samuel Shaw
2014-0076 · Tony Brown
Pedestrians crossing a 60mph unlit trunk road from a holiday park face extreme danger due to poor visibility, lack of warning signs …
North East
North Northumberland
 Highways Agency All Responded 1/1
26 Feb 2014 Hazel Polkinghorn
2014-0078 · Stuart Fisher
The easy online acquisition of dangerous non-prescribed medication, like Pentobarbital, poses a significant risk of future deaths, necessitating government intervention to regulate …
East Midlands
Central Lincolnshire
 Ministry of Justice Historic (No Identified Response) 0/1
26 Feb 2014 Bertram Hamilton
2014-0080 · Robin Balmain
The coroner was concerned that a nurse appeared not to know that insulin should not be given to a person whose blood …
West Midlands
Black Country
 Nursing and Midwifery Council Historic (No Identified Response) 0/1
26 Feb 2014 Sean Cunningham
2014-0087 · S P Fisher
A persistent design flaw in ejection seats allows strap misrouting, posing a significant risk, and manufacturers lack a robust system for urgently …
East Midlands
Lincolnshire (Central)
 Martin-Baker the MOD Historic (No Identified Response) 0/2
26 Feb 2014 Herta Woods
2014-0081 · Veronica Hamilton-Deeley
Multiple failures in patient care included apparent abandonment, poor documentation, lack of senior review, incorrect fluid management leading to overload, and inappropriate …
South East
Brighton & Hove
 Brighton and Sussex University Hospitals Historic (No Identified Response) 0/1
25 Feb 2014 Rachel Burke
2014-0074 · Andrew Harris
An adventure company misrepresented ascent altitudes, leading to unsafe rates for altitude sickness prevention. The trek leader prioritized cost over urgent medical …
London
London (Inner South)
 ABTA - The Travel Association Himalayan Encounters Ministry of Culture, Tourism and … Adventure Company Partially Responded 1/6
25 Feb 2014 Andre Matei
2014-0089 · Andrew Walker
The coroner noted the lack of national guidance on the role of interpreters during labour, particularly when an interpreter is required in …
London
London (North)
 Department of Health and Social … All Responded 1/1
25 Feb 2014 Stephen Palmer
2014-0072 · Veronica Hamilton-Deeley
Multiple failures, including delayed assessments, lack of senior review, inappropriate unit transfer, and a complete CT scanning service failure, led to critical …
South East
Brighton & Hove
 Brighton and Sussex University Hospitals Historic (No Identified Response) 0/1
Lee MacPherson Historic (No Identified Response)
3 Mar 2014 London 0/4 responses
Delayed police risk assessments and a lack of common understanding between escort and prison staff regarding critical handover documentation posed significant safety risks during …
HMP Wormwood Scrubs Metropolitan Police National Offender Management Service
Carl Morris All Responded
3 Mar 2014 North West 1/1 responses
Professional Association of Diving …
Marco Lima De Araujo All Responded
3 Mar 2014 South East 1/1 responses
There is no formal protocol for reporting and coordinating rescue efforts during life-threatening incidents in Portsmouth Harbour.
Queen’s Harbour Master Portsmouth
Kevin Pearson Historic (No Identified Response)
3 Mar 2014 Yorkshire and the Humber 0/1 responses
The company potentially failed to ensure full compliance with health and safety guidance for drivers and verify their understanding of critical instructions for specialized …
John Somerscales Ltd
Margaret Easterfield Historic (No Identified Response)
3 Mar 2014 South East 0/1 responses
A rare anastomotic leak following surgery, leading to the patient's death, raises concerns about a potential technical error by the surgeon.
East Kent University Hospital
Nathan Douthwaite Partially Responded
28 Feb 2014 North East 1/3 responses
A rectal biopsy would likely have diagnosed Hirschsprung's disease, highlighting concerns about current diagnostic guidelines and the trust's practices in this regard.
County Durham and Darlington … Department of Health and … National Institute for Health …
Peter Norman Nott All Responded
28 Feb 2014 South East 1/1 responses
Care home staff failed to perform adequate neurological observations following a patient's fall, relying on simple visual checks despite prolonged immobility and clear deterioration.
Rush Court Nursing Home
Richard White All Responded
28 Feb 2014 North East 1/1 responses
Hope House lacked a formal, documented policy or protocol for medication administration, which was unknown to prescribers and not made available to staff.
700 Club
Malcolm Potter Historic (No Identified Response)
27 Feb 2014 East of England 0/1 responses
The pedestrian crossing's warning light system is inadequately positioned and not synchronized for multiple trains, creating a significant re-crossing risk on a busy commuter …
Network Rail
Victoria Meppen-Walter Historic (No Identified Response)
27 Feb 2014 North West 0/2 responses
Concerns were raised regarding the easy online availability and regulation of chloroquine, along with the associated risks of its misuse.
Department of Health and … Medicines and Healthcare Products …
Maureen Leaver Historic (No Identified Response)
27 Feb 2014 South East 0/1 responses
Inadequate medical supervision and ineffective systems for investigating acutely ill elderly patients in a psychiatric ward were identified, alongside a lack of understanding of …
Sussex Partnership NHS Foundation …
Sidney Harvey Historic (No Identified Response)
26 Feb 2014 East Midlands 0/1 responses
Non-safety glass doors in rented properties, particularly where vulnerable individuals reside, pose a risk, and there is no clear system for their replacement or …
South Kesteven District Council
Samuel Shaw All Responded
26 Feb 2014 North East 1/1 responses
Pedestrians crossing a 60mph unlit trunk road from a holiday park face extreme danger due to poor visibility, lack of warning signs for drivers, …
Highways Agency
Hazel Polkinghorn Historic (No Identified Response)
26 Feb 2014 East Midlands 0/1 responses
The easy online acquisition of dangerous non-prescribed medication, like Pentobarbital, poses a significant risk of future deaths, necessitating government intervention to regulate such websites.
Ministry of Justice
Bertram Hamilton Historic (No Identified Response)
26 Feb 2014 West Midlands 0/1 responses
The coroner was concerned that a nurse appeared not to know that insulin should not be given to a person whose blood sugars were …
Nursing and Midwifery Council
Sean Cunningham Historic (No Identified Response)
26 Feb 2014 East Midlands 0/2 responses
A persistent design flaw in ejection seats allows strap misrouting, posing a significant risk, and manufacturers lack a robust system for urgently disseminating safety-critical …
Martin-Baker the MOD
Herta Woods Historic (No Identified Response)
26 Feb 2014 South East 0/1 responses
Multiple failures in patient care included apparent abandonment, poor documentation, lack of senior review, incorrect fluid management leading to overload, and inappropriate cannulation, all …
Brighton and Sussex University …
Rachel Burke Partially Responded
25 Feb 2014 London 1/6 responses
An adventure company misrepresented ascent altitudes, leading to unsafe rates for altitude sickness prevention. The trek leader prioritized cost over urgent medical care and …
ABTA - The Travel … Himalayan Encounters Ministry of Culture, Tourism …
Andre Matei All Responded
25 Feb 2014 London 1/1 responses
The coroner noted the lack of national guidance on the role of interpreters during labour, particularly when an interpreter is required in theatre.
Department of Health and …
Stephen Palmer Historic (No Identified Response)
25 Feb 2014 South East 0/1 responses
Multiple failures, including delayed assessments, lack of senior review, inappropriate unit transfer, and a complete CT scanning service failure, led to critical deterioration and …
Brighton and Sussex University …