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 310 of 317
Showing 20 at a time
Date Report Region / area Addressee(s) Status Responses
11 Dec 2013 Damion Stanley Joseph Henson
2013-0307 · Ian Smith
A homeless unit, housing drug users, lacked 24-hour supervision, allowing unauthorized individuals to enter out of hours, thereby increasing risks in a …
North West
Cumbria (South & East)
 Riverview, 62 Lound Road, Kendal Riverview, 62 Lound Road, Kendal Historic (No Identified Response) 0/2
9 Dec 2013 Anthony Hughes
2013-0352 · Andre Rebello
Police officers lacked awareness of "excited delirium," suggesting that training on this condition could improve responses in future incidents, despite appropriate actions …
North West
Liverpool
 National Crime Agency Historic (No Identified Response) 0/1
6 Dec 2013 Keith Barton
2013-0330 · Patricia Harding
There was a lack of clarity in dysphagia supervision recommendations, insufficient training for all staff on dysphagia awareness, and a failure to …
South East
Mid Kent and Medway
 Ashley Gardens Nursing Home All Responded 1/1
6 Dec 2013 Millie Elizabeth Thompson
2013-0356 · John Pollard
Nursery staff lacked sufficient and updated paediatric first aid training. Ambulance call-takers misinterpreted breathing, causing incorrect triage, and emergency vehicles were inadequately …
North West
Manchester (South)
 North West Ambulance Service Trust Department for Education Department for Health All Responded 3/3
6 Dec 2013 Kirk Duboise
2013-0329 · Andrew Tweddle
There was a delay in summoning an ambulance and an inadequate self-harm risk assessment for a new prisoner, as essential forms were …
North East
County Durham and Darlington
 Care UK Prison Service Partially Responded 1/2
5 Dec 2013 Karl Doran
2013-0328 · Andrew Tweddle
The theme park failed to conduct appropriate risk assessments for volunteers, and there was a complete absence of direct or indirect managerial …
North East
County Durham and Darlington
 Beamish Museum HSE Historic (No Identified Response) 0/2
5 Dec 2013 Desmond Statton
2013-0379 · Andrew Cox
The provided text describes a procedural step (blood sampling) but does not detail any specific concerns.
South West
Plymouth, Torbay & South Devon
 Derriford Hospital, Plymouth Historic (No Identified Response) 0/1
4 Dec 2013 Keith Thomas Graham
2013-0327 · D.Ll. Roberts
The report identifies a need to review procedures for seriously injured trauma patients arriving at the A&E, including summoning clinicians, CT scanning …
North West
North and West Cumbria
 North Cumbria University Hospitals NHS … Historic (No Identified Response) 0/1
4 Dec 2013 Archibold Wellbelove
2013-0324 · R Brittain
The Council failed to review its night-lighting policy for roads, creating unsafe conditions for pedestrians who regularly use unlit areas and may …
West Midlands
Warwickshire
 Warwickshire County Council All Responded 1/1
4 Dec 2013 Yuki Ivy Norman-Knight
2013-0321 · David Osborne
Concerns include fragmented patient record access, lack of clear guidelines for practice nurse referrals to doctors, and insufficient triggers for receptionists to …
East of England
Norfolk
 St Stephens Gate Medical Practice All Responded 1/1
4 Dec 2013 Marjorie Evelyne Keogh
2013-0325 · Donald Coutts-Wood
The care home failed to assess suitability for a first-floor room, had staffing level concerns, and a manager was often absent. Conflicting …
East Midlands
Leicester City and South Leicestershire
 Mymill Ltd. c/o Scraptoft Court … All Responded 2/1
3 Dec 2013 Agostino Costa
2013-0322 · M E Hassell
Staff confusion over patient falls risk classification and junior doctors' lack of training in post-fall management created significant safety concerns, exacerbated by …
London
Inner North London
 The Whittington Hospital NHS Trust Historic (No Identified Response) 0/1
3 Dec 2013 Abdullahi Sharif Abokar
2013-0323 · Mary Hassell
Mental health staff failed to assess suicide risk due to misconceptions, and resuscitation efforts were critically compromised by inadequate airway management, unactivated …
London
Inner North London
 Camden & Islington NHS Foundation … All Responded 1/1
3 Dec 2013 Horace Cottom
2013-0351 · Nigel Meadows
North West
Manchester City
 Secretary of State for Health the NHS HMPS HMP Manchester Historic (No Identified Response) 0/6
2 Dec 2013 Michael James Meyler
2013-0320 · Caroline Sarah Sumeray
Prison systems failed to adequately circulate self-harm/suicide risk information to relevant staff and attach it to ACCT documents, leading to uninformed decisions …
North West
Manchester City
 HMPS HMP Manchester Partially Responded 1/2
2 Dec 2013 Karl Olof Nilsson
2013-0332 · Caroline Sarah Sumeray
The junction's layout, gradient, and an obscured STOP sign created an optical illusion, making the sign difficult to perceive, which substantially contributed …
Yorkshire and the Humber
West Yorkshire (Western)
 National Highways Bradford Metropolitan District Council Historic (No Identified Response) 0/2
1 Dec 2013 John William Tugwell
2013-0319 · Martin Fleming
The care home allowed a high-risk patient with a documented history of falls unsupervised access to stairs, despite the clear potential for …
South East
Surrey
 Coombe Dingle Nursing Home Historic (No Identified Response) 0/1
28 Nov 2013 Doris Phoebe Miller
2013-0318 · Tom Osborne
Patient medical records were unavailable to the GP surgery after a practice closure, indicating a failure in transferring and making accessible essential …
South East
Milton Keynes
 Care Quality Commission NHS England Hertfordshire and South … Historic (No Identified Response) 0/2
27 Nov 2013 Peter Jeffrey
2013-0313 · Jacqueline Devonish
Hospital staff failed to consider alternative diagnoses or treatments, did not take cultures from an infected blister, and overlooked intravenous antibiotics after …
London
Eastern District of London
 Guys & St Thomas'NHS Foundation … All Responded 1/1
27 Nov 2013 Edna Elsie Mary Eden
2013-0317 · Peter James Bedford
Significant delays in providing prescribed antibiotics, infrequent observations with an incorrectly calculated risk score, and failures in escalating concerns about patient review …
South East
Berkshire
 Wexham Park Hospital Trust All Responded 1/1
Damion Stanley Joseph Henson Historic (No Identified Response)
11 Dec 2013 North West 0/2 responses
A homeless unit, housing drug users, lacked 24-hour supervision, allowing unauthorized individuals to enter out of hours, thereby increasing risks in a facility not …
Riverview, 62 Lound Road, … Riverview, 62 Lound Road, …
Anthony Hughes Historic (No Identified Response)
9 Dec 2013 North West 0/1 responses
Police officers lacked awareness of "excited delirium," suggesting that training on this condition could improve responses in future incidents, despite appropriate actions in the …
National Crime Agency
Keith Barton All Responded
6 Dec 2013 South East 1/1 responses
There was a lack of clarity in dysphagia supervision recommendations, insufficient training for all staff on dysphagia awareness, and a failure to complete incident …
Ashley Gardens Nursing Home
Millie Elizabeth Thompson All Responded
6 Dec 2013 North West 3/3 responses
Nursery staff lacked sufficient and updated paediatric first aid training. Ambulance call-takers misinterpreted breathing, causing incorrect triage, and emergency vehicles were inadequately equipped with …
North West Ambulance Service … Department for Education Department for Health
Kirk Duboise Partially Responded
6 Dec 2013 North East 1/2 responses
There was a delay in summoning an ambulance and an inadequate self-harm risk assessment for a new prisoner, as essential forms were not reviewed …
Care UK Prison Service
Karl Doran Historic (No Identified Response)
5 Dec 2013 North East 0/2 responses
The theme park failed to conduct appropriate risk assessments for volunteers, and there was a complete absence of direct or indirect managerial supervision over …
Beamish Museum HSE
Desmond Statton Historic (No Identified Response)
5 Dec 2013 South West 0/1 responses
The provided text describes a procedural step (blood sampling) but does not detail any specific concerns.
Derriford Hospital, Plymouth
Keith Thomas Graham Historic (No Identified Response)
4 Dec 2013 North West 0/1 responses
The report identifies a need to review procedures for seriously injured trauma patients arriving at the A&E, including summoning clinicians, CT scanning contraindications, and …
North Cumbria University Hospitals …
Archibold Wellbelove All Responded
4 Dec 2013 West Midlands 1/1 responses
The Council failed to review its night-lighting policy for roads, creating unsafe conditions for pedestrians who regularly use unlit areas and may be unaware …
Warwickshire County Council
Yuki Ivy Norman-Knight All Responded
4 Dec 2013 East of England 1/1 responses
Concerns include fragmented patient record access, lack of clear guidelines for practice nurse referrals to doctors, and insufficient triggers for receptionists to book doctor …
St Stephens Gate Medical …
Marjorie Evelyne Keogh All Responded
4 Dec 2013 East Midlands 2/1 responses
The care home failed to assess suitability for a first-floor room, had staffing level concerns, and a manager was often absent. Conflicting risk assessments …
Mymill Ltd. c/o Scraptoft …
Agostino Costa Historic (No Identified Response)
3 Dec 2013 London 0/1 responses
Staff confusion over patient falls risk classification and junior doctors' lack of training in post-fall management created significant safety concerns, exacerbated by inadequate sharing …
The Whittington Hospital NHS …
Abdullahi Sharif Abokar All Responded
3 Dec 2013 London 1/1 responses
Mental health staff failed to assess suicide risk due to misconceptions, and resuscitation efforts were critically compromised by inadequate airway management, unactivated oxygen, and …
Camden & Islington NHS …
Horace Cottom Historic (No Identified Response)
3 Dec 2013 North West 0/6 responses
Secretary of State for … the NHS HMPS
Michael James Meyler Partially Responded
2 Dec 2013 North West 1/2 responses
Prison systems failed to adequately circulate self-harm/suicide risk information to relevant staff and attach it to ACCT documents, leading to uninformed decisions and a …
HMPS HMP Manchester
Karl Olof Nilsson Historic (No Identified Response)
2 Dec 2013 Yorkshire and the Humber 0/2 responses
The junction's layout, gradient, and an obscured STOP sign created an optical illusion, making the sign difficult to perceive, which substantially contributed to the …
National Highways Bradford Metropolitan District Council
John William Tugwell Historic (No Identified Response)
1 Dec 2013 South East 0/1 responses
The care home allowed a high-risk patient with a documented history of falls unsupervised access to stairs, despite the clear potential for serious injury.
Coombe Dingle Nursing Home
Doris Phoebe Miller Historic (No Identified Response)
28 Nov 2013 South East 0/2 responses
Patient medical records were unavailable to the GP surgery after a practice closure, indicating a failure in transferring and making accessible essential patient information.
Care Quality Commission NHS England Hertfordshire and …
Peter Jeffrey All Responded
27 Nov 2013 London 1/1 responses
Hospital staff failed to consider alternative diagnoses or treatments, did not take cultures from an infected blister, and overlooked intravenous antibiotics after negative DVT …
Guys & St Thomas'NHS …
Edna Elsie Mary Eden All Responded
27 Nov 2013 South East 1/1 responses
Significant delays in providing prescribed antibiotics, infrequent observations with an incorrectly calculated risk score, and failures in escalating concerns about patient review delays compromised …
Wexham Park Hospital Trust