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.

Response tracker Themes Organisations Advanced search
6,327 reports · Page 311 of 317
Showing 20 at a time
Date Report Region / area Addressee(s) Status Responses
27 Nov 2013 Christopher Scott
2013-0350 · David Ridley
The 'legal high' AMT is readily available for purchase despite clear evidence of its deadly effects, raising concerns about its unregulated status …
South West
Wiltshire & Swindon
 House of Commons Historic (No Identified Response) 0/1
26 Nov 2013 Barry James Lewis
2013-0314 · Lisa Hashmi
Critical deficiencies exist in the emergency department, including inadequate availability and consistency of emergency airway equipment, insufficient backup instruments, poor out-of-hours theatre …
North West
Manchester North
 Pennine Acute Hospitals NHS Trust All Responded 1/1
26 Nov 2013 Alan Stanfield Browning
2013-0315 · Simon Fox
A vulnerable patient was discharged from a care facility without family notification or proper accommodation arrangements, specifically on a Friday, highlighting a …
South West
Avon
 Somewhere House Historic (No Identified Response) 0/1
22 Nov 2013 Christopher James Morgan
2013-0272 · William Morris
The Trust lacks clear policies for communicating risk level changes and leave access with family, and has no defined staff-to-patient ratio for …
East of England
Cambridgeshire
 Cambridgeshire and Peterborough NHS Foundation … Historic (No Identified Response) 0/1
22 Nov 2013 Garrett Joseph Franklin Elsey
2013-0316 · Terence G. Moore
A document on people in commercial waste containers ('Waste 25') may not have been read widely in the waste industry, and an …
South West
Avon
 HSE's Waste and Recycling Sector … Historic (No Identified Response) 0/1
21 Nov 2013 Daniel Maurice McMahon
2013-0271 · Andrew Walker
The report suggests improving information gathering by police when someone is trespassing on railway tracks; using feedback forms for patients on S17 …
London
London
 Department of Health and Social … LAS Legal Services Metropolitan Police RSSB Partially Responded 2/4
21 Nov 2013 Peter Galea
2013-0310 · Derek Winter
Mental health services had limited mechanisms to break the 'ping pong' referral cycle between agencies, and GPs faced limitations in directly admitting …
North East
City of Sunderland
 Department of Health Historic (No Identified Response) 0/1
21 Nov 2013 Lisa Jane Clayton
2013-0309 · Lisa Hashmi
Inadequate physical deterrents on a car park wall, insufficient CCTV monitoring and understaffed security, coupled with a history of similar incidents, highlight …
North West
Manchester North
 Kennedy Wilson Europe (as Landlord) Public Protection, Oldham Council, Chadderton … Savilles Management Resources (as the … The Spindles Town Square Shopping … Historic (No Identified Response) 0/4
20 Nov 2013 Luke Jacob Goodwin
2013-0311 · Mary Teresa Burke
The unrestricted sale of large helium canisters without flow control valves, combined with readily available online suicide guides, facilitates self-harm and raises …
Yorkshire and the Humber
West Yorkshire (Western)
 House of Commons Historic (No Identified Response) 0/1
20 Nov 2013 Annie Jones
2013-0306 · John Gittins
An inadequate mobility assessment led to the unsafe use of a stand aid for a non-weight-bearing resident. Staff lacked awareness of limitations …
Wales
North Wales (East & Central)
 Abbeydale Residential Home, Princes Drive, … All Responded 1/1
18 Nov 2013 Stuart Aaron Collins
2013-0300 · Clare Bailey
Inadequate patient assessment and a complete failure to conduct hourly observations or maintain accurate nursing notes for an epileptic patient. Furthermore, a …
North East
Teesside
 Cleveland Police Tees, Esk and Wear Valleys … James Cook University Hospital, South … Partially Responded 1/3
15 Nov 2013 David Cox
2013-0355 · Sophie Cartwright
The narrow bridleway with acute, blind bends and no safety barrier poses a significant risk of vehicles leaving the track and falling …
East Midlands
Derby & Derbyshire
 The Peak District National Park … All Responded 1/1
15 Nov 2013 Andrew Phrydas
2013-0301 · ME Hassell
London Underground lacked a process for simultaneous dual-line shutdown at intersecting stations and failed to alert the train driver directly and effectively …
London
London Inner North
 London Underground Historic (No Identified Response) 0/1
14 Nov 2013 Dean Griffiths
2013-0299 · Rachel Redman
Insufficient time allocated for exercises created pressure, preventing Range Conducting Officers from completing crucial final assurance checks.
South East
Kent (Central & South East)
 House of Commons Historic (No Identified Response) 0/1
14 Nov 2013 Anthony Brian Flynn
2013-0297 · Jennifer Leeming
Seriously ill prisoners were inhumanely shackled during medical examinations, clinician concerns were ignored, and there was inadequate training for prison officers regarding …
North West
Manchester West
 Department of Health and Social … HMP Forest Bank Partially Responded 1/2
14 Nov 2013 Kevin Paul Sutton
2013-0375 · Kevin Paul Sutton
The Trust failed to prepare essential care plans for patients discharged from its wards to other establishments, risking inadequate ongoing care.
South West
West Somerset
 Somerset Partnership NHS Foundation Trust Historic (No Identified Response) 0/1
13 Nov 2013 Barnabas Newlyn
2013-0382 · Selena Lynch
Road transfer times for time-sensitive critical care, particularly neurosurgical emergencies, are too long, necessitating earlier consideration and use of air transfer services.
London
London Inner (North)
 NHS England All Responded 1/1
11 Nov 2013 Timothy Clayton
2013-0361-wp26757 · ME Hassell
Police improperly pressured the grieving family regarding organ donation, and an officer subverted the coroner's judicial decision, leading to the loss of …
London
London Inner (North)
 Kent Police All Responded 1/1
11 Nov 2013 William Joseph Wilkinson
2013-0294 · John Pollard
Deficient one-to-one nursing, computer system failures, incomplete medical records, and absence of direct orthopaedic input in A&E contributed to an unnecessary admission …
North West
Manchester South
 Royal Bolton Hospital Historic (No Identified Response) 0/1
11 Nov 2013 Kathleen Rosemary Dixon
2013-0292 · Ian Smith
Repeated critical incidents in the Trust, evident across multiple inquests, necessitate an independent assessment of its operations.
North West
Cumbria (South & East)
 Care Quality Commission Department of Health Partially Responded 1/2
Christopher Scott Historic (No Identified Response)
27 Nov 2013 South West 0/1 responses
The 'legal high' AMT is readily available for purchase despite clear evidence of its deadly effects, raising concerns about its unregulated status and accessibility …
House of Commons
Barry James Lewis All Responded
26 Nov 2013 North West 1/1 responses
Critical deficiencies exist in the emergency department, including inadequate availability and consistency of emergency airway equipment, insufficient backup instruments, poor out-of-hours theatre access, and …
Pennine Acute Hospitals NHS …
Alan Stanfield Browning Historic (No Identified Response)
26 Nov 2013 South West 0/1 responses
A vulnerable patient was discharged from a care facility without family notification or proper accommodation arrangements, specifically on a Friday, highlighting a lack of …
Somewhere House
Christopher James Morgan Historic (No Identified Response)
22 Nov 2013 East of England 0/1 responses
The Trust lacks clear policies for communicating risk level changes and leave access with family, and has no defined staff-to-patient ratio for escorted leave …
Cambridgeshire and Peterborough NHS …
Garrett Joseph Franklin Elsey Historic (No Identified Response)
22 Nov 2013 South West 0/1 responses
A document on people in commercial waste containers ('Waste 25') may not have been read widely in the waste industry, and an alert system …
HSE's Waste and Recycling …
Daniel Maurice McMahon Partially Responded
21 Nov 2013 London 2/4 responses
The report suggests improving information gathering by police when someone is trespassing on railway tracks; using feedback forms for patients on S17 MHA leave; …
Department of Health and … LAS Legal Services Metropolitan Police
Peter Galea Historic (No Identified Response)
21 Nov 2013 North East 0/1 responses
Mental health services had limited mechanisms to break the 'ping pong' referral cycle between agencies, and GPs faced limitations in directly admitting patients to …
Department of Health
Lisa Jane Clayton Historic (No Identified Response)
21 Nov 2013 North West 0/4 responses
Inadequate physical deterrents on a car park wall, insufficient CCTV monitoring and understaffed security, coupled with a history of similar incidents, highlight serious failures …
Kennedy Wilson Europe (as … Public Protection, Oldham Council, … Savilles Management Resources (as …
Luke Jacob Goodwin Historic (No Identified Response)
20 Nov 2013 Yorkshire and the Humber 0/1 responses
The unrestricted sale of large helium canisters without flow control valves, combined with readily available online suicide guides, facilitates self-harm and raises serious safety …
House of Commons
Annie Jones All Responded
20 Nov 2013 Wales 1/1 responses
An inadequate mobility assessment led to the unsafe use of a stand aid for a non-weight-bearing resident. Staff lacked awareness of limitations and proper …
Abbeydale Residential Home, Princes …
Stuart Aaron Collins Partially Responded
18 Nov 2013 North East 1/3 responses
Inadequate patient assessment and a complete failure to conduct hourly observations or maintain accurate nursing notes for an epileptic patient. Furthermore, a hazardous item …
Cleveland Police Tees, Esk and Wear … James Cook University Hospital, …
David Cox All Responded
15 Nov 2013 East Midlands 1/1 responses
The narrow bridleway with acute, blind bends and no safety barrier poses a significant risk of vehicles leaving the track and falling into the …
The Peak District National …
Andrew Phrydas Historic (No Identified Response)
15 Nov 2013 London 0/1 responses
London Underground lacked a process for simultaneous dual-line shutdown at intersecting stations and failed to alert the train driver directly and effectively when a …
London Underground
Dean Griffiths Historic (No Identified Response)
14 Nov 2013 South East 0/1 responses
Insufficient time allocated for exercises created pressure, preventing Range Conducting Officers from completing crucial final assurance checks.
House of Commons
Anthony Brian Flynn Partially Responded
14 Nov 2013 North West 1/2 responses
Seriously ill prisoners were inhumanely shackled during medical examinations, clinician concerns were ignored, and there was inadequate training for prison officers regarding hospital escorts …
Department of Health and … HMP Forest Bank
Kevin Paul Sutton Historic (No Identified Response)
14 Nov 2013 South West 0/1 responses
The Trust failed to prepare essential care plans for patients discharged from its wards to other establishments, risking inadequate ongoing care.
Somerset Partnership NHS Foundation …
Barnabas Newlyn All Responded
13 Nov 2013 London 1/1 responses
Road transfer times for time-sensitive critical care, particularly neurosurgical emergencies, are too long, necessitating earlier consideration and use of air transfer services.
NHS England
Timothy Clayton All Responded
11 Nov 2013 London 1/1 responses
Police improperly pressured the grieving family regarding organ donation, and an officer subverted the coroner's judicial decision, leading to the loss of six organs.
Kent Police
William Joseph Wilkinson Historic (No Identified Response)
11 Nov 2013 North West 0/1 responses
Deficient one-to-one nursing, computer system failures, incomplete medical records, and absence of direct orthopaedic input in A&E contributed to an unnecessary admission and subsequent …
Royal Bolton Hospital
Kathleen Rosemary Dixon Partially Responded
11 Nov 2013 North West 1/2 responses
Repeated critical incidents in the Trust, evident across multiple inquests, necessitate an independent assessment of its operations.
Care Quality Commission Department of Health