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 308 of 317
Showing 20 at a time
Date Report Region / area Addressee(s) Status Responses
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 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
10 Jan 2014 Pauline Meredith
2014-0011 · Margaret Jones
Concerns include prolonged prescribing of excessive medication without review, adding morphine to a high-dose regimen for an alcohol-dependent patient, and a GP's …
West Midlands
Staffordshire South
 Browning Street Surgery General Medical Council Partially Responded 1/2
10 Jan 2014 Mary Waldron
2014-0127 · R Brittain
Nursing home staff failed to recognise and act on an acutely unwell resident due to inadequate ongoing training and poor internal investigation. …
West Midlands
Coventry
 Care Quality Commission Nursing and Midwifery Council St Mary’s Nursing Home West Midlands Ambulance Service University … Historic (No Identified Response) 0/4
10 Jan 2014 Dr Edward Slaney
2014-0030 · Melanie Williamson
There is a lack of established criteria and guidance for planning authorities to assess the wind effects of tall buildings on the …
Yorkshire and the Humber
West Yorkshire (East)
 Ministry of Housing, Communities & … Historic (No Identified Response) 0/1
9 Jan 2014 Albert James Hand
2014-0010 · Tom Osborne
The coroner reported concerns about a patient with a head injury waiting over an hour and a half for transport to hospital, …
East of England
Bedfordshire & Luton
 East of England Ambulance Service All Responded 1/1
8 Jan 2014 Jonathan Thorpe
2014-0006 · John Pollard
A GP failed to consult or refer a known self-harmer to Mental Health Services, prescribing medication without adequate assessment of his ongoing …
North West
Manchester (South)
 King Street Medical Centre Historic (No Identified Response) 0/1
7 Jan 2014 Grace Mary Bates
2014-0007 · Andrew Walker
The hospital lacked a specialist diabetic nurse available over the weekend, posing a risk to patients requiring specific care.
London
London (North)
 Barnet and Chase Farm Hospitals … Department of Health and Social … All Responded 2/2
7 Jan 2014 James Withers
2014-0004 · John Pollard
Key concerns include significant delays in specialist consultation, missing medical notes, and poor communication with family regarding the Do Not Attempt Resuscitation …
North West
Manchester (South)
 Tameside Hospital NHS Foundation Trust Historic (No Identified Response) 0/1
7 Jan 2014 Andrew John Fallon
2014-0005 · John Pollard
Emergency Department staffing levels were critically insufficient, causing excessive delays for seriously ill patients as staff were overwhelmed by patient volume, including …
North West
Manchester (South)
 Stockton NHS Foundation Trust Historic (No Identified Response) 0/1
6 Jan 2014 Chloe Grace Flavell
2014-0003 · Maria Voisin
The reception area management, prior to triage, creates significant and dangerous delays in providing immediate care and treatment, particularly for children.
South West
Avon
 Weston Area Health NHS Trust Historic (No Identified Response) 0/1
6 Jan 2014 Daniel Williams
2014-0009 · Nicola Mundy
Key concerns include inadequate staff training in record-keeping and communication, absence of clear guidance for checking for self-harm items, and no central …
Yorkshire and the Humber
South Yorkshire (East)
 Rotherham, Doncaster and South Humberside … All Responded 1/1
6 Jan 2014 Billy Paul Thomas Salton
2014-0002 · Joanne Kearsley
GMP policy of not staffing the Prisoner Processing Unit overnight leads to unnecessary and prolonged custody times for individuals awaiting interview.
North West
Manchester (South)
 GEO AMEY MEDACS Greater Manchester Police Partially Responded 2/3
6 Jan 2014 Martin McGlasson
2014-0001 · Robert Chapman
Widespread use of an unsafe work method, failure to implement inexpensive safety measures despite known risks, and inadequate dissemination of risk assessments …
North West
Cumbria (North & West)
 British Precast Concrete Federation All Responded 1/1
3 Jan 2014 Keith Fleming
2014-0008 · Terence Carney
The provided text indicates that matters of concern were revealed but does not detail what these specific concerns are.
North East
Gateshead & South Tyneside
 Newcastle upon Tyne Hospitals NHS … North of England Commissioning Report South Tyneside NHS Foundation Trust Trinity Medical Centre Historic (No Identified Response) 0/4
31 Dec 2013 Adrian John Pickard
2013-0358 · Melanie Williamson
Company vehicles laden with aggregates are not routinely weighed before departing the premises, posing potential safety risks on public highways.
Yorkshire and the Humber
West Yorkshire (East)
 Lightwater Quarries Limited All Responded 1/1
30 Dec 2013 Lynne Dring
2013-0360 · Paul Kelly
Street furniture obstructed motorists' views, and non-prescribed white lines may have falsely induced pedestrians to believe they had priority, creating a road …
Yorkshire and the Humber
North Lincolnshire & Grimsby
 North East Lincolnshire Council All Responded 1/1
27 Dec 2013 Simon Sankey
2013-0361 · Alan Walsh
The categorisation of mental health referrals was done by an unqualified administration assistant, with no subsequent review of the urgency category, and …
North West
Manchester (West)
 5 Boroughs Partnership NHS Foundation … All Responded 1/1
20 Dec 2013 Roy Frank Fletcher
2013-0362 · Alan Wilson
The Trust's post-incident review was inadequate, failing to interview a key witness or assess if similar events were persistent issues, thus hindering …
North West
Blackpool & Fylde
 Lancashire Care NHS Foundation Trust Historic (No Identified Response) 0/1
20 Dec 2013 Adrian Johnson
2013-0364 · Andrew Harris
The coroner noted that initial screening did not assess for tobacco withdrawal, ACCT reviews lacked healthcare input, and there was a lack …
London
London (Inner South)
 HMP Belmarsh National Offender Management Service NHS England Partially Responded 1/3
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
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
Pauline Meredith Partially Responded
10 Jan 2014 West Midlands 1/2 responses
Concerns include prolonged prescribing of excessive medication without review, adding morphine to a high-dose regimen for an alcohol-dependent patient, and a GP's perceived reluctance …
Browning Street Surgery General Medical Council
Mary Waldron Historic (No Identified Response)
10 Jan 2014 West Midlands 0/4 responses
Nursing home staff failed to recognise and act on an acutely unwell resident due to inadequate ongoing training and poor internal investigation. Communication issues …
Care Quality Commission Nursing and Midwifery Council St Mary’s Nursing Home
Dr Edward Slaney Historic (No Identified Response)
10 Jan 2014 Yorkshire and the Humber 0/1 responses
There is a lack of established criteria and guidance for planning authorities to assess the wind effects of tall buildings on the safety of …
Ministry of Housing, Communities …
Albert James Hand All Responded
9 Jan 2014 East of England 1/1 responses
The coroner reported concerns about a patient with a head injury waiting over an hour and a half for transport to hospital, insufficient ambulance …
East of England Ambulance …
Jonathan Thorpe Historic (No Identified Response)
8 Jan 2014 North West 0/1 responses
A GP failed to consult or refer a known self-harmer to Mental Health Services, prescribing medication without adequate assessment of his ongoing mental health …
King Street Medical Centre
Grace Mary Bates All Responded
7 Jan 2014 London 2/2 responses
The hospital lacked a specialist diabetic nurse available over the weekend, posing a risk to patients requiring specific care.
Barnet and Chase Farm … Department of Health and …
James Withers Historic (No Identified Response)
7 Jan 2014 North West 0/1 responses
Key concerns include significant delays in specialist consultation, missing medical notes, and poor communication with family regarding the Do Not Attempt Resuscitation (DNAR) status. …
Tameside Hospital NHS Foundation …
Andrew John Fallon Historic (No Identified Response)
7 Jan 2014 North West 0/1 responses
Emergency Department staffing levels were critically insufficient, causing excessive delays for seriously ill patients as staff were overwhelmed by patient volume, including minor complaints.
Stockton NHS Foundation Trust
Chloe Grace Flavell Historic (No Identified Response)
6 Jan 2014 South West 0/1 responses
The reception area management, prior to triage, creates significant and dangerous delays in providing immediate care and treatment, particularly for children.
Weston Area Health NHS …
Daniel Williams All Responded
6 Jan 2014 Yorkshire and the Humber 1/1 responses
Key concerns include inadequate staff training in record-keeping and communication, absence of clear guidance for checking for self-harm items, and no central summary sheet …
Rotherham, Doncaster and South …
Billy Paul Thomas Salton Partially Responded
6 Jan 2014 North West 2/3 responses
GMP policy of not staffing the Prisoner Processing Unit overnight leads to unnecessary and prolonged custody times for individuals awaiting interview.
GEO AMEY MEDACS Greater Manchester Police
Martin McGlasson All Responded
6 Jan 2014 North West 1/1 responses
Widespread use of an unsafe work method, failure to implement inexpensive safety measures despite known risks, and inadequate dissemination of risk assessments to operating …
British Precast Concrete Federation
Keith Fleming Historic (No Identified Response)
3 Jan 2014 North East 0/4 responses
The provided text indicates that matters of concern were revealed but does not detail what these specific concerns are.
Newcastle upon Tyne Hospitals … North of England Commissioning … South Tyneside NHS Foundation …
Adrian John Pickard All Responded
31 Dec 2013 Yorkshire and the Humber 1/1 responses
Company vehicles laden with aggregates are not routinely weighed before departing the premises, posing potential safety risks on public highways.
Lightwater Quarries Limited
Lynne Dring All Responded
30 Dec 2013 Yorkshire and the Humber 1/1 responses
Street furniture obstructed motorists' views, and non-prescribed white lines may have falsely induced pedestrians to believe they had priority, creating a road safety risk.
North East Lincolnshire Council
Simon Sankey All Responded
27 Dec 2013 North West 1/1 responses
The categorisation of mental health referrals was done by an unqualified administration assistant, with no subsequent review of the urgency category, and the electronic …
5 Boroughs Partnership NHS …
Roy Frank Fletcher Historic (No Identified Response)
20 Dec 2013 North West 0/1 responses
The Trust's post-incident review was inadequate, failing to interview a key witness or assess if similar events were persistent issues, thus hindering learning and …
Lancashire Care NHS Foundation …
Adrian Johnson Partially Responded
20 Dec 2013 London 1/3 responses
The coroner noted that initial screening did not assess for tobacco withdrawal, ACCT reviews lacked healthcare input, and there was a lack of consistency …
HMP Belmarsh National Offender Management Service NHS England