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 306 of 317

Showing 20 at a time

Date	Report	Region / area	Addressee(s)	Status	Responses
3 Feb 2014	Daniel Collins 2014-0058 · Ian Arrow The provided text indicates that matters of concern were revealed but does not detail what these specific concerns are.	South West Plymouth, Torbay & South Devon	Devon and Cornwall Police Plymouth City Council	Historic (No Identified Response)	0/2
3 Feb 2014	Daniel Jones 2014-0049 · Stephen Nicholls Insufficient road signage, including warning triangles and white arrows, at a specific junction on the A356 creates a hazard, necessitating improved signage …	South West Dorset	Dorset Highways Management	All Responded	1/1
3 Feb 2014	Ryan Clark 2014-0057 · Melanie Williamson Prison procedures like the Personal Officer Scheme, ACCT checks, and roll call were not properly implemented. Additionally, prison officers lacked sufficient first …	Yorkshire and the Humber West Yorkshire (East)	National Offender Management Service	All Responded	2/1
3 Feb 2014	Amanda Vickers 2014-0052 · D LI Roberts A severe shortage of specialist crisis home beds, with no clear availability, contributed to a patient's death while awaiting admission, highlighting inadequate …	North West Cumbria (North & West)	NHS Cumbria Clinical Commissioning Group	All Responded	1/1
3 Feb 2014	Amy Friar 2014-0051 · Richard Travers The absence of universal emergency codes across the prison estate creates confusion for transferring staff, risking delays in emergency response.	South East Surrey	Ministry of Justice	Historic (No Identified Response)	0/1
3 Feb 2014	Michael Telford 2014-0045 · D LI Roberts	North West Cumbria (North & West)	Cumbria County Council	Historic (No Identified Response)	0/1
3 Feb 2014	Scarlett Sinclair 2014-0059 · Maria Voisin The policy for assessing a baby's wellness and stability prior to transfer between neonatal units needs urgent review, as babies are being …	South West Avon	Oxford University Hospitals NHS Trust	Historic (No Identified Response)	0/1
31 Jan 2014	Shaun Elliott 2014-0042 · Richard Hulett The coroner noted that a missing person coordinator was not in post at weekends, that Shaun's family expressed a number of concerns …	South East Buckinghamshire	College of Policing	Historic (No Identified Response)	0/1
31 Jan 2014	Lee Bonsall 2014-0044 · Jonathan Layton Citalopram was inappropriately given on repeat prescription, contravening guidelines. Moreover, long ten-month waiting times for psychotherapy make it an unviable treatment alternative.	Wales Carmarthenshire & Pembrokeshire	Department of Health and Social …	All Responded	2/1
31 Jan 2014	William Kent 2014-0056 · Karen Henderson Staff lacked awareness and received insufficient training on the harmful side-effects of Haz-Tab granules when used with urine, compounded by unclear usage …	South East Surrey	Guest Medical Medicines and Healthcare products Regulatory … St Peter’s and Ashford Hospitals	Historic (No Identified Response)	0/3
31 Jan 2014	Ryan Chapman 2014-0048 · Penelope Schofield Staff lacked understanding of patient leave policies and support worker roles. Delayed risk assessments, insufficient family information, and poor ward security were …	South East West Sussex	Sussex Partnership NHS Trust	Historic (No Identified Response)	0/1
30 Jan 2014	Leslie Pates 2014-0043 · John Pollard A complete breakdown in hospital and social services communication with the family occurred. The patient was discharged against family wishes with severe …	North West Manchester (South)	Tameside Metropolitan Borough Council Tameside NHS Foundation Trust	Partially Responded	1/2
30 Jan 2014	Gareth Slater 2014-0050 · Joanne Kearsley Discharge planning failed due to clinical impasses, resulting in no care plan, insufficient family involvement, inadequate independent living assessment, and an unsuitable …	North West Manchester (South)	Oldham Borough Council Pennine Care NHS Foundation Trust	Historic (No Identified Response)	0/2
30 Jan 2014	Tallulah Wilson 2014-0047 · ME Hassell Healthcare professionals lacked sufficient understanding of young people's evolving internet use and online lives. Digital lives training is not standard for psychiatric …	London London Inner (North)	Department of Health and Social …	All Responded	1/1
27 Jan 2014	Judith Marshall 2014-0039 · William Coverdale The pharmacy showed unpoliced drug errors and dispensing mistakes despite checks. Concerns include lack of alert software, mandatory read-back procedures, and a …	Yorkshire and the Humber York	Department of Health and Social … General Pharmaceutical Council NHS England Royal Pharmaceutical Society of Great …	All Responded	4/4
27 Jan 2014	Pamela Bailey 2014-0040 · Donald Coutts-Wood Delays in implementing improved door security, inadequate weekend staffing, and the lack of a patient photograph for police when she disappeared, were …	Yorkshire and the Humber South Yorkshire (West)	Sheffield Trust	Historic (No Identified Response)	0/1
27 Jan 2014	Umul Audu 2014-0038 · R Brittain The lack of transport heater availability during patient transfers risks future patients suffering hypothermia, potentially leading to death.	London London Inner (North)	University College London Hospitals NHS …	All Responded	1/1
26 Jan 2014	Lillian Robinson 2014-0041 · Martin Flemimg The report text did not detail specific concerns, only indicating that matters giving rise to a risk of future deaths were identified.	South East Surrey	Surrey County Council	Historic (No Identified Response)	0/1
24 Jan 2014	Elizabeth Turnbull 2014-0035 · Nicola Mundy The close proximity of thumbwheel controls, coupled with the absence of dual controls, increased the risk of inadvertently releasing locking pins for …	Yorkshire and the Humber South Yorkshire (East)	British Industrial Truck Association HM Principle Specialist Inspector	Historic (No Identified Response)	0/2
24 Jan 2014	Bertha Cray 2014-0037 · R Brittain Inadvertent alteration of 'nil by mouth' signage is possible due to easily turned double-sided signs and an unclear cause of previous alteration, …	London London Inner (North)	Barts Health NHS Trust	All Responded	1/1

Daniel Collins Historic (No Identified Response)

3 Feb 2014 South West 0/2 responses

The provided text indicates that matters of concern were revealed but does not detail what these specific concerns are.

Devon and Cornwall Police Plymouth City Council

Daniel Jones All Responded

3 Feb 2014 South West 1/1 responses

Insufficient road signage, including warning triangles and white arrows, at a specific junction on the A356 creates a hazard, necessitating improved signage or reduced …

Dorset Highways Management

Ryan Clark All Responded

3 Feb 2014 Yorkshire and the Humber 2/1 responses

Prison procedures like the Personal Officer Scheme, ACCT checks, and roll call were not properly implemented. Additionally, prison officers lacked sufficient first aid and …

National Offender Management Service

Amanda Vickers All Responded

3 Feb 2014 North West 1/1 responses

A severe shortage of specialist crisis home beds, with no clear availability, contributed to a patient's death while awaiting admission, highlighting inadequate commissioning by …

NHS Cumbria Clinical Commissioning …

Amy Friar Historic (No Identified Response)

3 Feb 2014 South East 0/1 responses

The absence of universal emergency codes across the prison estate creates confusion for transferring staff, risking delays in emergency response.

Ministry of Justice

Michael Telford Historic (No Identified Response)

3 Feb 2014 North West 0/1 responses

Cumbria County Council

Scarlett Sinclair Historic (No Identified Response)

3 Feb 2014 South West 0/1 responses

The policy for assessing a baby's wellness and stability prior to transfer between neonatal units needs urgent review, as babies are being transferred in …

Oxford University Hospitals NHS …

Shaun Elliott Historic (No Identified Response)

31 Jan 2014 South East 0/1 responses

The coroner noted that a missing person coordinator was not in post at weekends, that Shaun's family expressed a number of concerns and frustrations …

College of Policing

Lee Bonsall All Responded

31 Jan 2014 Wales 2/1 responses

Citalopram was inappropriately given on repeat prescription, contravening guidelines. Moreover, long ten-month waiting times for psychotherapy make it an unviable treatment alternative.

Department of Health and …

William Kent Historic (No Identified Response)

31 Jan 2014 South East 0/3 responses

Staff lacked awareness and received insufficient training on the harmful side-effects of Haz-Tab granules when used with urine, compounded by unclear usage instructions.

Guest Medical Medicines and Healthcare products … St Peter’s and Ashford …

Ryan Chapman Historic (No Identified Response)

31 Jan 2014 South East 0/1 responses

Staff lacked understanding of patient leave policies and support worker roles. Delayed risk assessments, insufficient family information, and poor ward security were identified issues.

Sussex Partnership NHS Trust

Leslie Pates Partially Responded

30 Jan 2014 North West 1/2 responses

A complete breakdown in hospital and social services communication with the family occurred. The patient was discharged against family wishes with severe pressure sores …

Tameside Metropolitan Borough Council Tameside NHS Foundation Trust

Gareth Slater Historic (No Identified Response)

30 Jan 2014 North West 0/2 responses

Discharge planning failed due to clinical impasses, resulting in no care plan, insufficient family involvement, inadequate independent living assessment, and an unsuitable unfurnished flat.

Oldham Borough Council Pennine Care NHS Foundation …

Tallulah Wilson All Responded

30 Jan 2014 London 1/1 responses

Healthcare professionals lacked sufficient understanding of young people's evolving internet use and online lives. Digital lives training is not standard for psychiatric or medical …

Department of Health and …

Judith Marshall All Responded

27 Jan 2014 Yorkshire and the Humber 4/4 responses

The pharmacy showed unpoliced drug errors and dispensing mistakes despite checks. Concerns include lack of alert software, mandatory read-back procedures, and a central error …

Department of Health and … General Pharmaceutical Council NHS England

Pamela Bailey Historic (No Identified Response)

27 Jan 2014 Yorkshire and the Humber 0/1 responses

Delays in implementing improved door security, inadequate weekend staffing, and the lack of a patient photograph for police when she disappeared, were significant concerns.

Sheffield Trust

Umul Audu All Responded

27 Jan 2014 London 1/1 responses

The lack of transport heater availability during patient transfers risks future patients suffering hypothermia, potentially leading to death.

University College London Hospitals …

Lillian Robinson Historic (No Identified Response)

26 Jan 2014 South East 0/1 responses

The report text did not detail specific concerns, only indicating that matters giving rise to a risk of future deaths were identified.

Surrey County Council

Elizabeth Turnbull Historic (No Identified Response)

24 Jan 2014 Yorkshire and the Humber 0/2 responses

The close proximity of thumbwheel controls, coupled with the absence of dual controls, increased the risk of inadvertently releasing locking pins for excavator attachments.

British Industrial Truck Association HM Principle Specialist Inspector

Bertha Cray All Responded

24 Jan 2014 London 1/1 responses

Inadvertent alteration of 'nil by mouth' signage is possible due to easily turned double-sided signs and an unclear cause of previous alteration, risking recurrence.

Barts Health NHS Trust