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 313 of 317

Showing 20 at a time

Date	Report	Region / area	Addressee(s)	Status	Responses
21 Oct 2013	Elsie Gibson 2013-0267 · Dr RN Palmer The Council, as Highways Authority, failed to promptly investigate and take action against an unlicensed scaffold tower that narrowed a pavement, leading …	London South London	Bromley Council	Historic (No Identified Response)	0/1
21 Oct 2013	Mark Stephen Smith 2013-0268 · Andrew Walker Guidance is needed for emergency services on when to remain on the line with a person who has taken an intentional overdose …	London London (North)	London Ambulance Service	Historic (No Identified Response)	0/1
21 Oct 2013	Brian Belfield 2013-0270 · Robert Chapman Failures in race management included an inaccurate system for tracking participants, lack of a single responsible person for checks, and unreliable communication …	North West Cumbria (North and West)	Fell Runners Association	Historic (No Identified Response)	0/1
18 Oct 2013	Jennifer Rushworth 2013-0264 · John Pollard Significant delays in cardiology reviews, lack of surgeon input in theatre booking, and insufficient surgeons contributed to surgical delays, potentially impacting patient …	North West Manchester South	Stepping Hill Hospital	Historic (No Identified Response)	0/1
18 Oct 2013	Elizabeth Aurora Kerr 2013-0276 · Nigel Meadows The provided text is truncated, making it impossible to identify the specific safety concerns raised by the All-Party Parliamentary Gas Safety Group.	North West Manchester City	All Party Parliamentary Gas Safety … Association of Chief Fire Officers Department for Energy and Climate … Greater Manchester Fire and Rescue …	Historic (No Identified Response)	0/9
17 Oct 2013	Brian Dorling and Philippine de Gerin-Ricard 2013-0265 · Mary Hassell Confusing unbordered blue strips for cyclists, insufficient education on safer riding techniques, and a dangerous junction contribute to increased road safety risks …	London London (Inner North)	Transport for London	All Responded	1/1
17 Oct 2013	Rosa Anderson 2013-0263 · Andre Rebello The patient was discharged without a summary, written information on her operation, critical advice, or emergency contact numbers.	North West Liverpool	Aintree Hospitals NHS Trust	All Responded	1/1
16 Oct 2013	Janet Richardson 2013-0261 · David Roberts The deceased fell into the sea during a rescue medical evacuation.	North West Cumbria (North & West)	Cruise and Maritime Services International … Newmarket Promotions Limited Redningsselskapet	Partially Responded	2/3
16 Oct 2013	John James Jackson 2013-0260 · Robin Balmain The coroner notes a lack of readily available information about the dangers of consuming large quantities of caffeine, particularly from 'Hero Energy …	West Midlands Black Country	Department of Health and Social …	Historic (No Identified Response)	0/1
14 Oct 2013	Frederick Davidson 2013-0258 · Martin Flemimg Inadequate note-keeping, inappropriate use of a nasogastric tube given the patient's history, unexplained gaps in clinical notes, communication breakdown between junior doctor …	South East Surrey	Department of Health and Social … Epsom and St Helier University …	Historic (No Identified Response)	0/2
14 Oct 2013	Yousef Shokri-Gharab 2013-0239-wp23943 · Andre Rebello An outdated and unreviewed policy for informal patient leave failed to reflect current practice, risking patient safety due to lack of multidisciplinary …	North West Liverpool	Mersey Care, NHS Trust	All Responded	1/1
12 Oct 2013	Carol Ann Gibson 2013-0183 · Nicholas Rheinberg A GP ignored a critical adverse drug reaction alert, exacerbated by a culture of 'alert fatigue' and dismissive attitudes towards patient safety …	North West Cheshire	Castlefields Health Centre NHS England	Historic (No Identified Response)	0/2
10 Oct 2013	James Edward Mansfield 2013-0288 · Mrs Cheney Delays in the GP surgery reviewing hospital discharge letters for serious injuries, combined with prescribing strong painkillers without an in-person assessment, posed …	East of England Cambridgeshire (South and West)	Nuffield Road Medical Centre	Historic (No Identified Response)	0/1
8 Oct 2013	Anthony Bernard Mcormick 2013-0255 · Nigel Meadows Urgent blood test results were not acted upon promptly, leading to a delay in necessary hospital admission.	North West Manchester City	Consultant Physician and Gastroenterologists East Cheshire NHS Trust	Historic (No Identified Response)	0/2
8 Oct 2013	Kuldip Singh Dhillon 2013-0254 · Chinyere Inyama Widespread common practice of unrestrained palletised loads on vehicles poses significant safety risks, compounded by insufficient enforcement and auditing of transport regulations …	London London (East)	Department for Transport	Historic (No Identified Response)	0/1
4 Oct 2013	Walter Gordon Powley 2013-0251 · Donald Coutts-Wood Uncovered, excessively hot pipes and radiator valves in a care home posed a burn risk. This was compounded by a lack of …	East Midlands Leicester City & South Leicestershire	Care Quality Commission Health and Safety Executive, Head … Registered Nursing Home Association	All Responded	3/3
4 Oct 2013	George Leonard Parkes 2013-0252 · Sarah Ormond-Walshe Failure to follow up on a patient with an abdominal aortic aneurysm led to its rupture and death. A specialist nurse clinic …	West Midlands Birmingham and Solihull	University Hospitals Birmingham NHS Foundation …	Historic (No Identified Response)	0/1
4 Oct 2013	Jean James 2013-0207 · Andrew Cox Patients admitted via their GP experienced significant delays in medical review compared to those from the Emergency Department, with one patient waiting …	South West Cornwall	Rule 43 Archivist, Coroner Society … Office of the Chief Coroner Royal Cornwall Hospital	Historic (No Identified Response)	0/3
3 Oct 2013	Douglas Grey 2013-0253 · Chinyere Inyama Lack of clear written procedures for equipment delivery, installation, and review. Carers also failed to recognise and report faulty equipment despite a …	London London (East)	Consumer Relations and Legal Affairs Floron Residential Home	Historic (No Identified Response)	0/2
3 Oct 2013	Ishmail Kubilay 2013-0248 · Edward Thomas The Prison Ombudsman's clinic review identified healthcare deficiencies with national implications, but the specific recommendations are truncated in the provided text.	East of England Hertfordshire	Department of Health and Social … Ministry of Justice	Historic (No Identified Response)	0/2

Elsie Gibson Historic (No Identified Response)

21 Oct 2013 London 0/1 responses

The Council, as Highways Authority, failed to promptly investigate and take action against an unlicensed scaffold tower that narrowed a pavement, leading to a …

Bromley Council

Mark Stephen Smith Historic (No Identified Response)

21 Oct 2013 London 0/1 responses

Guidance is needed for emergency services on when to remain on the line with a person who has taken an intentional overdose and is …

London Ambulance Service

Brian Belfield Historic (No Identified Response)

21 Oct 2013 North West 0/1 responses

Failures in race management included an inaccurate system for tracking participants, lack of a single responsible person for checks, and unreliable communication between race …

Fell Runners Association

Jennifer Rushworth Historic (No Identified Response)

18 Oct 2013 North West 0/1 responses

Significant delays in cardiology reviews, lack of surgeon input in theatre booking, and insufficient surgeons contributed to surgical delays, potentially impacting patient outcomes.

Stepping Hill Hospital

Elizabeth Aurora Kerr Historic (No Identified Response)

18 Oct 2013 North West 0/9 responses

The provided text is truncated, making it impossible to identify the specific safety concerns raised by the All-Party Parliamentary Gas Safety Group.

All Party Parliamentary Gas … Association of Chief Fire … Department for Energy and …

Brian Dorling and Philippine de Gerin-Ricard All Responded

17 Oct 2013 London 1/1 responses

Confusing unbordered blue strips for cyclists, insufficient education on safer riding techniques, and a dangerous junction contribute to increased road safety risks for both …

Transport for London

Rosa Anderson All Responded

17 Oct 2013 North West 1/1 responses

The patient was discharged without a summary, written information on her operation, critical advice, or emergency contact numbers.

Aintree Hospitals NHS Trust

Janet Richardson Partially Responded

16 Oct 2013 North West 2/3 responses

The deceased fell into the sea during a rescue medical evacuation.

Cruise and Maritime Services … Newmarket Promotions Limited Redningsselskapet

John James Jackson Historic (No Identified Response)

16 Oct 2013 West Midlands 0/1 responses

The coroner notes a lack of readily available information about the dangers of consuming large quantities of caffeine, particularly from 'Hero Energy Mints', which …

Department of Health and …

Frederick Davidson Historic (No Identified Response)

14 Oct 2013 South East 0/2 responses

Inadequate note-keeping, inappropriate use of a nasogastric tube given the patient's history, unexplained gaps in clinical notes, communication breakdown between junior doctor and consultant, …

Department of Health and … Epsom and St Helier …

Yousef Shokri-Gharab All Responded

14 Oct 2013 North West 1/1 responses

An outdated and unreviewed policy for informal patient leave failed to reflect current practice, risking patient safety due to lack of multidisciplinary consensus and …

Mersey Care, NHS Trust

Carol Ann Gibson Historic (No Identified Response)

12 Oct 2013 North West 0/2 responses

A GP ignored a critical adverse drug reaction alert, exacerbated by a culture of 'alert fatigue' and dismissive attitudes towards patient safety warnings within …

Castlefields Health Centre NHS England

James Edward Mansfield Historic (No Identified Response)

10 Oct 2013 East of England 0/1 responses

Delays in the GP surgery reviewing hospital discharge letters for serious injuries, combined with prescribing strong painkillers without an in-person assessment, posed risks to …

Nuffield Road Medical Centre

Anthony Bernard Mcormick Historic (No Identified Response)

8 Oct 2013 North West 0/2 responses

Urgent blood test results were not acted upon promptly, leading to a delay in necessary hospital admission.

Consultant Physician and Gastroenterologists East Cheshire NHS Trust

Kuldip Singh Dhillon Historic (No Identified Response)

8 Oct 2013 London 0/1 responses

Widespread common practice of unrestrained palletised loads on vehicles poses significant safety risks, compounded by insufficient enforcement and auditing of transport regulations by the …

Department for Transport

Walter Gordon Powley All Responded

4 Oct 2013 East Midlands 3/3 responses

Uncovered, excessively hot pipes and radiator valves in a care home posed a burn risk. This was compounded by a lack of specific room …

Care Quality Commission Health and Safety Executive, … Registered Nursing Home Association

George Leonard Parkes Historic (No Identified Response)

4 Oct 2013 West Midlands 0/1 responses

Failure to follow up on a patient with an abdominal aortic aneurysm led to its rupture and death. A specialist nurse clinic and dedicated …

University Hospitals Birmingham NHS …

Jean James Historic (No Identified Response)

4 Oct 2013 South West 0/3 responses

Patients admitted via their GP experienced significant delays in medical review compared to those from the Emergency Department, with one patient waiting six hours.

Rule 43 Archivist, Coroner … Office of the Chief … Royal Cornwall Hospital

Douglas Grey Historic (No Identified Response)

3 Oct 2013 London 0/2 responses

Lack of clear written procedures for equipment delivery, installation, and review. Carers also failed to recognise and report faulty equipment despite a written policy, …

Consumer Relations and Legal … Floron Residential Home

Ishmail Kubilay Historic (No Identified Response)

3 Oct 2013 East of England 0/2 responses

The Prison Ombudsman's clinic review identified healthcare deficiencies with national implications, but the specific recommendations are truncated in the provided text.

Department of Health and … Ministry of Justice