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 307 of 317
Showing 20 at a time
Date Report Region / area Addressee(s) Status Responses
24 Jan 2014 Alfred Hodges
2014-0033 · Nicola Jones
Conwy's Telecare package lacks standard interlinked smoke alarms, and interim safety provisions are unclear. Additionally, the deceased was not offered a free …
Wales
North Central & North East Wales
 Conwy County Council All Responded 1/1
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
23 Jan 2014 Desrae Tucker
2014-0032 · Wendy James
Inadequate recording of anti-embolic stocking use, no consideration for discharging the patient with them, and failure to prescribe anti-coagulant medication upon discharge …
Wales
Gwent
 Aneurin Bevan Health Board Historic (No Identified Response) 0/1
22 Jan 2014 Paul Rogerson
2014-0029 · William Coverdale
River safety equipment is inadequate, poorly maintained, and lacks proper warning signs. Gaps exist in police river rescue training, inter-agency communication, and …
Yorkshire and the Humber
York
 City of York Council North Yorkshire Fire and Rescue … North Yorkshire Police Historic (No Identified Response) 0/3
21 Jan 2014 Kyle Ashley Smith
2014-0028 · Jennifer Leeming
An urgent mental health referral from a GP was significantly delayed in reaching the assessment team, with the reason for this critical …
North West
Manchester (West)
 Longshoot Health Centre Historic (No Identified Response) 0/1
21 Jan 2014 William Dowling & Victoria Rose
2014-0027 · David Ridley
There's no national system allowing doctors to proactively share concerns about a patient's ongoing suitability for a firearms license, with patient confidentiality …
South West
Wiltshire & Swindon
 Association of Chief Police Officers British Medical Association Firearms and Explosive Licensing Working … Hampshire Constabulary Historic (No Identified Response) 0/8
21 Jan 2014 Christine Nutbeam
2014-0025 · Peter Bedford
Critical information about a patient's symptoms was not transferred between hospitals or communicated to surgical teams, and pre-operative checks lacked a standard …
South East
Berkshire
 St Peter’s Hospital Wexham Park Hospital Historic (No Identified Response) 0/2
21 Jan 2014 John Malone
2014-0026 · John Pollard
A hospital discharge letter was critically deficient, lacking essential patient admission and discharge details, which hindered the GP's ability to provide appropriate …
North West
Manchester (South)
 Tameside Hospital NHS Foundation Trust Historic (No Identified Response) 0/1
21 Jan 2014 Mone White
2014-0031 · Andrew Walker
There is no system to ensure specialist hospital advice for patients with complex clinical requirements is consistently communicated to all treating clinicians.
London
London (North)
 Department of Health and Social … Northwick Park Hospital All Responded 2/2
21 Jan 2014 Frederick Pring
2014-0024 · John Gittins
Current practices for patient handover at Emergency Departments lead to unacceptable delays, keeping ambulances occupied and unavailable for other critical calls.
Wales
North Wales (East & Central)
 Betsi Cadwaladr University Health Board All Responded 1/1
17 Jan 2014 Julia Dell
2014-0021 · Andrew Cox
The medical service received from primary care was exemplary during the period examined, with no concerns identified in the provided text.
South West
Cornwall
 Royal Cornwall Hospital Trust Medical Centre Stratton, Bude, Cornwall Historic (No Identified Response) 0/3
17 Jan 2014 Julie Ann Camm
2014-0023 · David Hincliff
A vulnerable tenant's property lacked smoke alarms because the housing association's policy only encouraged fire safety checks, failing to ensure installation and …
Yorkshire and the Humber
West Yorkshire (East)
 Leeds City Council All Responded 1/1
17 Jan 2014 Wayne Broad
2014-0020 · Andrew Walker
There is a lack of dedicated substance misuse teams in police custody and specialized nursing staff in hospitals. Police handcuffing policies for …
London
London (North)
 Association of Chief Police Officers Department of Health and Social … G4S Serco Partially Responded 1/4
16 Jan 2014 James Stokoe
2014-0019 · Derek Winter
Mental Health Services lack formal mechanisms to consult carers/partners, potentially missing vital information that could inform risk assessments and identify domestic abuse, …
North East
Sunderland
 Department of Health and Social … Historic (No Identified Response) 0/1
16 Jan 2014 Jackie Scott
2014-0022 · Tony Brown
Lack of clear allergen information meant the deceased unknowingly consumed peanuts in a take-away meal, resulting in a fatal anaphylactic shock.
North East
North Northumberland
 Indian Brasserie Historic (No Identified Response) 0/1
14 Jan 2014 Craig White
2014-0017 · ARW Forrest
Concerns include insufficient TB screening protocols before Infliximab treatment, inadequate prescriber awareness of increased TB risk, and the need for better patient …
East Midlands
South Lincolnshire
 British National Formulary British Society of Gastroenterology Intensive Care Society Lincolnshire Community Health Services NHS … Historic (No Identified Response) 0/7
14 Jan 2014 Russell James Felstead
2014-0016 · Joanne Kearlsey
Doctors failed to access and read vital medical information within nursing notes, resulting in a four-day delay in ordering an urgent CT …
North West
Manchester (South)
 Care Quality Commission Stepping Hill Hospital Choice Support Historic (No Identified Response) 0/3
13 Jan 2014 Jason Nock
2014-0013 · Robin Balmain
An entirely unregulated product is readily available without consumer information on safe dosage or potential consequences, leaving users unaware of the substance …
West Midlands
Black Country
 Home Office All Responded 1/1
13 Jan 2014 Mustafa Cicek
2014-0116 · Alan Craze
Highway safety issues include a collision black spot with inadequate warning signage and a potentially hazardous eucalyptus sapling. "SLOW" warnings are also …
South East
East Sussex
 Department for Transport National Highways The Chief Coroner Partially Responded 1/3
13 Jan 2014 Barbara White
2014-0015 · Joanne Kearsley
Critical lapses included a 12-hour absence of clinical observations, an incorrect PARS score that should have triggered intervention, and severe staff shortages. …
North West
Manchester (South)
 Tameside General Hospital Historic (No Identified Response) 0/1
Alfred Hodges All Responded
24 Jan 2014 Wales 1/1 responses
Conwy's Telecare package lacks standard interlinked smoke alarms, and interim safety provisions are unclear. Additionally, the deceased was not offered a free home fire …
Conwy County Council
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
Desrae Tucker Historic (No Identified Response)
23 Jan 2014 Wales 0/1 responses
Inadequate recording of anti-embolic stocking use, no consideration for discharging the patient with them, and failure to prescribe anti-coagulant medication upon discharge were issues.
Aneurin Bevan Health Board
Paul Rogerson Historic (No Identified Response)
22 Jan 2014 Yorkshire and the Humber 0/3 responses
River safety equipment is inadequate, poorly maintained, and lacks proper warning signs. Gaps exist in police river rescue training, inter-agency communication, and hypothermia first …
City of York Council North Yorkshire Fire and … North Yorkshire Police
Kyle Ashley Smith Historic (No Identified Response)
21 Jan 2014 North West 0/1 responses
An urgent mental health referral from a GP was significantly delayed in reaching the assessment team, with the reason for this critical communication failure …
Longshoot Health Centre
William Dowling & Victoria Rose Historic (No Identified Response)
21 Jan 2014 South West 0/8 responses
There's no national system allowing doctors to proactively share concerns about a patient's ongoing suitability for a firearms license, with patient confidentiality potentially overriding …
Association of Chief Police … British Medical Association Firearms and Explosive Licensing …
Christine Nutbeam Historic (No Identified Response)
21 Jan 2014 South East 0/2 responses
Critical information about a patient's symptoms was not transferred between hospitals or communicated to surgical teams, and pre-operative checks lacked a standard question about …
St Peter’s Hospital Wexham Park Hospital
John Malone Historic (No Identified Response)
21 Jan 2014 North West 0/1 responses
A hospital discharge letter was critically deficient, lacking essential patient admission and discharge details, which hindered the GP's ability to provide appropriate ongoing care.
Tameside Hospital NHS Foundation …
Mone White All Responded
21 Jan 2014 London 2/2 responses
There is no system to ensure specialist hospital advice for patients with complex clinical requirements is consistently communicated to all treating clinicians.
Department of Health and … Northwick Park Hospital
Frederick Pring All Responded
21 Jan 2014 Wales 1/1 responses
Current practices for patient handover at Emergency Departments lead to unacceptable delays, keeping ambulances occupied and unavailable for other critical calls.
Betsi Cadwaladr University Health …
Julia Dell Historic (No Identified Response)
17 Jan 2014 South West 0/3 responses
The medical service received from primary care was exemplary during the period examined, with no concerns identified in the provided text.
Royal Cornwall Hospital Trust Medical Centre Stratton, Bude, Cornwall
Julie Ann Camm All Responded
17 Jan 2014 Yorkshire and the Humber 1/1 responses
A vulnerable tenant's property lacked smoke alarms because the housing association's policy only encouraged fire safety checks, failing to ensure installation and increasing the …
Leeds City Council
Wayne Broad Partially Responded
17 Jan 2014 London 1/4 responses
There is a lack of dedicated substance misuse teams in police custody and specialized nursing staff in hospitals. Police handcuffing policies for seriously ill …
Association of Chief Police … Department of Health and … G4S
James Stokoe Historic (No Identified Response)
16 Jan 2014 North East 0/1 responses
Mental Health Services lack formal mechanisms to consult carers/partners, potentially missing vital information that could inform risk assessments and identify domestic abuse, especially in …
Department of Health and …
Jackie Scott Historic (No Identified Response)
16 Jan 2014 North East 0/1 responses
Lack of clear allergen information meant the deceased unknowingly consumed peanuts in a take-away meal, resulting in a fatal anaphylactic shock.
Indian Brasserie
Craig White Historic (No Identified Response)
14 Jan 2014 East Midlands 0/7 responses
Concerns include insufficient TB screening protocols before Infliximab treatment, inadequate prescriber awareness of increased TB risk, and the need for better patient education and …
British National Formulary British Society of Gastroenterology Intensive Care Society
Russell James Felstead Historic (No Identified Response)
14 Jan 2014 North West 0/3 responses
Doctors failed to access and read vital medical information within nursing notes, resulting in a four-day delay in ordering an urgent CT scan for …
Care Quality Commission Stepping Hill Hospital Choice Support
Jason Nock All Responded
13 Jan 2014 West Midlands 1/1 responses
An entirely unregulated product is readily available without consumer information on safe dosage or potential consequences, leaving users unaware of the substance they are …
Home Office
Mustafa Cicek Partially Responded
13 Jan 2014 South East 1/3 responses
Highway safety issues include a collision black spot with inadequate warning signage and a potentially hazardous eucalyptus sapling. "SLOW" warnings are also needed on …
Department for Transport National Highways The Chief Coroner
Barbara White Historic (No Identified Response)
13 Jan 2014 North West 0/1 responses
Critical lapses included a 12-hour absence of clinical observations, an incorrect PARS score that should have triggered intervention, and severe staff shortages. Poor handover …
Tameside General Hospital