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 309 of 317
Showing 20 at a time
Date Report Region / area Addressee(s) Status Responses
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
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
19 Dec 2013 Kenneth Smalley
2013-0367 · Alan Walsh
A malfunctioning operating table and emergency stop, potentially linked to a damaged, improperly positioned handset, highlight inadequate pre-operation checks and a lack …
North West
Manchester (West)
 Eschmann Holdings Limited Medicines and Healthcare Products Regulatory … Wrightington, Wigan and Leigh Teaching … Partially Responded 1/3
19 Dec 2013 Leo Deady
2013-0369 · Phillip Barlow
A significant proportion of breech presentations go undiagnosed nationally, yet there are no national guidelines for routine late-pregnancy scans to detect them, …
London
London (Inner South)
 Department of Health and Social … Royal College of Obstetricians and … Partially Responded 1/2
19 Dec 2013 Michael Longley
2013-0370 · Rachael Redman
Difficulties in communication between Integrated Care 24 and the District Nursing Service highlight a need for improved oral and written communication methods.
South East
Central & South East Kent
 Kent Community Health NHS Foundation … Historic (No Identified Response) 0/1
18 Dec 2013 Christine Williamson
2013-0371 · John Ellery
Failure to assess the deceased as a vulnerable adult at risk from domestic violence and a critical lack of information sharing between …
West Midlands
Shropshire, Telford & Wrekin
 South Staffordshire and Shropshire Healthcare … Telford and Wrekin Clinical Commission … Telford and Wrekin Council West Mercia Police All Responded 3/4
17 Dec 2013 William Andrews
2013-0368 · Christopher Dorries
Surgical equipment design flaws, including the lack of a brightly coloured detachable cap on a bulb syringe, led to a retained tip. …
Yorkshire and the Humber
South Yorkshire (West)
 Care Quality Commission Department of Health and Social … Secretary of State for Health Partially Responded 1/3
17 Dec 2013 Sandra Wordingham
2013-0373 · John Woolley
A nursing home failed to seek timely medical opinion for an unconscious resident, delaying identification of a severe condition and risking unnecessary …
Wales
Cardiff & the Vale of Glamorgan
 Springbank Care Home Limited All Responded 1/1
17 Dec 2013 Sean Seabourne
2013-0374 · Geraint Williams
Systemic communication failures and unclear roles between mental health teams led to an urgent referral for a high-risk patient with suicide plans …
West Midlands
Worcestershire
 Worcestershire Health and Care NHS … Historic (No Identified Response) 0/1
17 Dec 2013 John Morgan
2013-0372 · John Woolley
Over-reliance on whiteboards rather than patient notes, the potential for human error to input incorrect information, and the use of a misleading …
Wales
Cardiff & the Vale of Glamorgan
 Cardiff and Vale University Health … Welsh Government Health and Social … Partially Responded 1/2
16 Dec 2013 Joseph Drew Whiteside
2013-0377 · Andrew Haigh
Numerous drownings of intoxicated individuals in the River Trent highlight the need for improved safety measures, such as fencing and warning signs, …
West Midlands
Staffordshire (South)
 East Staffordshire Borough Council All Responded 1/1
16 Dec 2013 Cynthia Fretwell
2013-0366 · Jane Gillespie
The GP practice had an ineffective system for telephone referrals, lacking timely consultation, proper assessment of patient mental capacity for refusing treatment, …
East Midlands
Nottinghamshire
 HAMA Medical Centre, NHS Commissioning … All Responded 1/1
16 Dec 2013 Sarah Shepherd
2013-0359 · Alison Hewitt
The Trust lacked a clear referral process for PICU and its documentation, while nursing staff misunderstood resuscitation guidelines due to unclear training …
South East
Surrey
 Surrey and Borders Partnership NHS … Historic (No Identified Response) 0/1
16 Dec 2013 Elsie May Treece
2013-0376 · Andrew Haigh
Hospital staff likely failed to report an incident where a patient fell during transfer, suggesting a need for better training and reminders …
West Midlands
Staffordshire (South)
 Burton Hospitals NHS Foundation Trust All Responded 1/1
16 Dec 2013 Clive Gould
2013-0357 · Nicholas Graham
Ambulance service failures include inappropriate priority allocation for calls, insufficient system resilience leading to delays, and inadequate communication with callers about estimated …
South East
Oxfordshire
 South Central Ambulance Service NHS … All Responded 1/1
13 Dec 2013 Stephanie Daniels
2013-0353 · Nigel Meadows
Significant deficiencies exist in internal SUI investigations, with errors and omissions, along with concerns about the thoroughness and independence of inquiries. Additionally, …
North West
Manchester City
 APEX Nursing Agency Care Quality Commission Department of Health and Social … Greater Manchester Mental Health NHS … All Responded 3/8
12 Dec 2013 William McCourt
2013-0383 · Robert Turnbull
Local residents' reports of flooding were not recorded or acted upon, and maintenance staff failed to correctly identify land ownership, leading to …
Yorkshire and the Humber
North Yorkshire (West)
 1. David Bowe All Responded 1/1
12 Dec 2013 Jane Dyson Gabbitas
2013-0326 · Timothy Harvey Ratcliffe
An open residential unit lacked a formal system to record and monitor resident absences, leading to staff being unaware of a resident's …
Yorkshire and the Humber
West Yorkshire (Western)
 South West Yorkshire Partnership NHS … The Chief Coroner Historic (No Identified Response) 0/2
12 Dec 2013 Rosemary Brownyn Ferguson
2013-0365 · Geoffrey Saul
Poor communication between hospital staff and Social Services led to a discharge without support. Unclear instructions given to a friend regarding patient …
Yorkshire and the Humber
South Yorkshire (East)
 Doncaster and Bassetlaw Teaching Hospitals … Historic (No Identified Response) 0/1
12 Dec 2013 Felix Cembrowicz
2013-0204 · Terence Moore
The electronic patient record system failed to migrate complete histories for discharged mental health patients, leaving current staff unaware of crucial past …
South West
Avon
 Avon and Wiltshire Mental Health … All Responded 1/1
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
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 …
Kenneth Smalley Partially Responded
19 Dec 2013 North West 1/3 responses
A malfunctioning operating table and emergency stop, potentially linked to a damaged, improperly positioned handset, highlight inadequate pre-operation checks and a lack of training …
Eschmann Holdings Limited Medicines and Healthcare Products … Wrightington, Wigan and Leigh …
Leo Deady Partially Responded
19 Dec 2013 London 1/2 responses
A significant proportion of breech presentations go undiagnosed nationally, yet there are no national guidelines for routine late-pregnancy scans to detect them, despite high …
Department of Health and … Royal College of Obstetricians …
Michael Longley Historic (No Identified Response)
19 Dec 2013 South East 0/1 responses
Difficulties in communication between Integrated Care 24 and the District Nursing Service highlight a need for improved oral and written communication methods.
Kent Community Health NHS …
Christine Williamson All Responded
18 Dec 2013 West Midlands 3/4 responses
Failure to assess the deceased as a vulnerable adult at risk from domestic violence and a critical lack of information sharing between agencies hindered …
South Staffordshire and Shropshire … Telford and Wrekin Clinical … Telford and Wrekin Council
William Andrews Partially Responded
17 Dec 2013 Yorkshire and the Humber 1/3 responses
Surgical equipment design flaws, including the lack of a brightly coloured detachable cap on a bulb syringe, led to a retained tip. A national …
Care Quality Commission Department of Health and … Secretary of State for …
Sandra Wordingham All Responded
17 Dec 2013 Wales 1/1 responses
A nursing home failed to seek timely medical opinion for an unconscious resident, delaying identification of a severe condition and risking unnecessary death if …
Springbank Care Home Limited
Sean Seabourne Historic (No Identified Response)
17 Dec 2013 West Midlands 0/1 responses
Systemic communication failures and unclear roles between mental health teams led to an urgent referral for a high-risk patient with suicide plans not being …
Worcestershire Health and Care …
John Morgan Partially Responded
17 Dec 2013 Wales 1/2 responses
Over-reliance on whiteboards rather than patient notes, the potential for human error to input incorrect information, and the use of a misleading DNR "red …
Cardiff and Vale University … Welsh Government Health and …
Joseph Drew Whiteside All Responded
16 Dec 2013 West Midlands 1/1 responses
Numerous drownings of intoxicated individuals in the River Trent highlight the need for improved safety measures, such as fencing and warning signs, at main …
East Staffordshire Borough Council
Cynthia Fretwell All Responded
16 Dec 2013 East Midlands 1/1 responses
The GP practice had an ineffective system for telephone referrals, lacking timely consultation, proper assessment of patient mental capacity for refusing treatment, and clear …
HAMA Medical Centre, NHS …
Sarah Shepherd Historic (No Identified Response)
16 Dec 2013 South East 0/1 responses
The Trust lacked a clear referral process for PICU and its documentation, while nursing staff misunderstood resuscitation guidelines due to unclear training and misleading …
Surrey and Borders Partnership …
Elsie May Treece All Responded
16 Dec 2013 West Midlands 1/1 responses
Hospital staff likely failed to report an incident where a patient fell during transfer, suggesting a need for better training and reminders on the …
Burton Hospitals NHS Foundation …
Clive Gould All Responded
16 Dec 2013 South East 1/1 responses
Ambulance service failures include inappropriate priority allocation for calls, insufficient system resilience leading to delays, and inadequate communication with callers about estimated arrival times …
South Central Ambulance Service …
Stephanie Daniels All Responded
13 Dec 2013 North West 3/8 responses
Significant deficiencies exist in internal SUI investigations, with errors and omissions, along with concerns about the thoroughness and independence of inquiries. Additionally, patient information …
APEX Nursing Agency Care Quality Commission Department of Health and …
William McCourt All Responded
12 Dec 2013 Yorkshire and the Humber 1/1 responses
Local residents' reports of flooding were not recorded or acted upon, and maintenance staff failed to correctly identify land ownership, leading to significant delays …
1. David Bowe
Jane Dyson Gabbitas Historic (No Identified Response)
12 Dec 2013 Yorkshire and the Humber 0/2 responses
An open residential unit lacked a formal system to record and monitor resident absences, leading to staff being unaware of a resident's prolonged disappearance …
South West Yorkshire Partnership … The Chief Coroner
Rosemary Brownyn Ferguson Historic (No Identified Response)
12 Dec 2013 Yorkshire and the Humber 0/1 responses
Poor communication between hospital staff and Social Services led to a discharge without support. Unclear instructions given to a friend regarding patient care, combined …
Doncaster and Bassetlaw Teaching …
Felix Cembrowicz All Responded
12 Dec 2013 South West 1/1 responses
The electronic patient record system failed to migrate complete histories for discharged mental health patients, leaving current staff unaware of crucial past contact and …
Avon and Wiltshire Mental …