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 315 of 317
Showing 20 at a time
Date Report Region / area Addressee(s) Status Responses
17 Sep 2013 Margaret Theresa Corrigan
2013-0233 · John Pollard
Ineffective communication, a missed fracture diagnosis in the Emergency Department, and inappropriate ward placement for medical issues contributed to patient harm. Procedural …
North West
Manchester South
 Stockport NHS Foundation Trust Historic (No Identified Response) 0/1
16 Sep 2013 Rachael Dallison
2013-0205 · Andrew Haigh
The provided concerns text is too truncated to identify specific safety issues.
West Midlands
Staffordshire (South)
 Commissioner for Transport Staffordshire County Council Historic (No Identified Response) 0/2
16 Sep 2013 Reggie John
2013-0202 · G U Williams
Poor communication and lack of written records between prisons compromised a high-risk prisoner's care. Failures included inadequate review processes and a nurse …
West Midlands
Worcestershire
 HMP Bristol HMP Hewell Worcestershire Health and Care NHS … Partially Responded 2/3
16 Sep 2013 George Renshaw Brown
2013-0230 · John Pollard
A lack of efficient systems for reassessing and transferring care home residents with rapidly deteriorating conditions led to significant delays in moving …
North West
Manchester South
 Bromleys Solicitors Care Quality Commission Fentons Solicitors Manchester Clinical Commissioning Group Historic (No Identified Response) 0/6
12 Sep 2013 Matthew Dunham
2013-0229 · William Armstrong
Failures in mental health care included delayed emergency referrals, unclear team roles, inadequate assessment of suicide risk, and critical breakdowns in information …
East of England
Norfolk
 Norfolk and Suffolk NHS Foundation … Historic (No Identified Response) 0/1
11 Sep 2013 Caroline Lee
2013-0228 · S McGovern
Medical staff failed to recognise the significance of abnormal potassium results, compounded by the laboratory's failure to inform ward staff promptly, hindering …
West Midlands
Coventry
 University Hospital Coventry and Warwickshire Historic (No Identified Response) 0/1
10 Sep 2013 David Douglas Hackman
2013-0346 · David Ridley
After a previous overdose attempt, a patient undergoing mental health assessment in a hospital unit was able to leave unnoticed, leading to …
South West
Wiltshire & Swindon
 NHS England Historic (No Identified Response) 0/1
9 Sep 2013 Ricky Anderson
2013-0227 · Patricia Harding
Mental health services failed to inform the GP of hospital admissions, relied excessively on family for post-discharge monitoring, and discharged a patient …
South East
Mid Kent and Medway
 Kent and Medway NHS Social Care Partnership Trust Historic (No Identified Response) 0/2
9 Sep 2013 Martin Daffydd Barker
2013-0226 · Joanne Kearsley
There appears to be no national guidance on how independent medical service providers, particularly those covering large public events, should operate, posing …
North West
Manchester South
 Department of Health and Social … Manchester Medical Service North West Ambulance Service Salford Royal Hospital NHS Trust Partially Responded 2/4
9 Sep 2013 John Michael Bailey
2013-0198 · Jullian Fox
Yorkshire and the Humber
South Yorkshire (West)
 Department of Health and Social … Historic (No Identified Response) 0/1
6 Sep 2013 Peter Pattinson
2013-0250 · Derek Winter
Care home staff failed to act on family requests for bed rail use and repairs, did not conduct risk assessments, and maintained …
North East
Sunderland
 European Care group All Responded 1/1
5 Sep 2013 Labhuden Amarshi Vaghadia
2013-0201 · Catherine Mason
A community nurse administered anticoagulant despite patient bleeding, failed to share critical information with other professionals, and demonstrated a lack of professional …
East Midlands
Leicester City & South Leicestershire
 Leicestershire Partnership NHS Trust All Responded 1/1
4 Sep 2013 Michael Irlam
2013-0224 · Andrew Bridgman
A significant 24-day waiting time between discharge from crisis mental health services and the first follow-up appointment creates a dangerous gap in …
North West
Manchester South
 Improving Access to Psychological Therapies Trafford Crisis Resolution and Home … Historic (No Identified Response) 0/2
4 Sep 2013 Karen Sutton
2013-0223 · Lydia Brown
Hospital departments failed to share patient admission information, leading to discharge without prophylactic medication and inadequate follow-up arrangements due to a lack …
East Midlands
Leicester City & South Leicestershire
 University Hospitals Leicester NHS Trust All Responded 1/1
30 Aug 2013 Jessica Ashton-Pyatt
2013-0200 · ARW Forrest
The emergency response was uncoordinated, lacked consultant leadership, and critical equipment like the defibrillator was uncharged with missing pads, compromising immediate patient …
East Midlands
South Lincolnshire
 United Lincolnshire Hospitals NHS Trust Historic (No Identified Response) 0/1
30 Aug 2013 May Gibson
2013-0199 · Christopher Dorries
The report identifies failures in obtaining and accounting for a community care assessment, performing pre-assessments, developing adequate care plans, conducting risk assessments, …
Yorkshire and the Humber
South Yorkshire (West)
 LNT Software Helios 47 Herries Lodge Care Home Historic (No Identified Response) 0/2
30 Aug 2013 Jack William Payton
2013-0220 · Michael Rose
Control room staff's judgement and handling of the matter were negatively affected by excessive working hours and heavy caseloads, raising concerns about …
South West
West Somerset
 Avon and Somerset Constabulary All Responded 1/1
29 Aug 2013 Martin Leslie Brown
2013-0209 · Tom Osborne
The certificate for a road resurfacing product (Milepave) contained ambiguous wording regarding speed limit applicability and road types, risking its inappropriate use …
South West
Gloucestershire
 British Board of Agreement Fletcher's Solicitors Gloucestershire Constabulary Gloucestershire Highways Partially Responded 1/7
28 Aug 2013 Dorothy Townley
2013-0219 · Joanne Kearsley
Significant communication breakdowns between District Nurses and the GP, inadequate burns treatment knowledge and training, and unclear procedures for urgent blood tests …
North West
Manchester (South)
 Royal College of General Practitioners Royal College of Nursing All Responded 1/2
28 Aug 2013 Terence O’Connell
2013-0218 · Louise Hunt
A severe communication breakdown between the care home, district nurses, and out-of-hours GP led to the patient not being seen, alongside a …
Wales
Bridgend, Glamorgan Valleys & Powys
 ABMU Health Board Grove Medical Centre Monkstone House Care Home Partially Responded 2/3
Margaret Theresa Corrigan Historic (No Identified Response)
17 Sep 2013 North West 0/1 responses
Ineffective communication, a missed fracture diagnosis in the Emergency Department, and inappropriate ward placement for medical issues contributed to patient harm. Procedural errors, such …
Stockport NHS Foundation Trust
Rachael Dallison Historic (No Identified Response)
16 Sep 2013 West Midlands 0/2 responses
The provided concerns text is too truncated to identify specific safety issues.
Commissioner for Transport Staffordshire County Council
Reggie John Partially Responded
16 Sep 2013 West Midlands 2/3 responses
Poor communication and lack of written records between prisons compromised a high-risk prisoner's care. Failures included inadequate review processes and a nurse not accessing …
HMP Bristol HMP Hewell Worcestershire Health and Care …
George Renshaw Brown Historic (No Identified Response)
16 Sep 2013 North West 0/6 responses
A lack of efficient systems for reassessing and transferring care home residents with rapidly deteriorating conditions led to significant delays in moving a patient …
Bromleys Solicitors Care Quality Commission Fentons Solicitors
Matthew Dunham Historic (No Identified Response)
12 Sep 2013 East of England 0/1 responses
Failures in mental health care included delayed emergency referrals, unclear team roles, inadequate assessment of suicide risk, and critical breakdowns in information sharing and …
Norfolk and Suffolk NHS …
Caroline Lee Historic (No Identified Response)
11 Sep 2013 West Midlands 0/1 responses
Medical staff failed to recognise the significance of abnormal potassium results, compounded by the laboratory's failure to inform ward staff promptly, hindering timely intervention.
University Hospital Coventry and …
David Douglas Hackman Historic (No Identified Response)
10 Sep 2013 South West 0/1 responses
After a previous overdose attempt, a patient undergoing mental health assessment in a hospital unit was able to leave unnoticed, leading to his subsequent …
NHS England
Ricky Anderson Historic (No Identified Response)
9 Sep 2013 South East 0/2 responses
Mental health services failed to inform the GP of hospital admissions, relied excessively on family for post-discharge monitoring, and discharged a patient early without …
Kent and Medway NHS Social Care Partnership Trust
Martin Daffydd Barker Partially Responded
9 Sep 2013 North West 2/4 responses
There appears to be no national guidance on how independent medical service providers, particularly those covering large public events, should operate, posing a risk …
Department of Health and … Manchester Medical Service North West Ambulance Service
John Michael Bailey Historic (No Identified Response)
9 Sep 2013 Yorkshire and the Humber 0/1 responses
Department of Health and …
Peter Pattinson All Responded
6 Sep 2013 North East 1/1 responses
Care home staff failed to act on family requests for bed rail use and repairs, did not conduct risk assessments, and maintained inadequate, unpaginated …
European Care group
Labhuden Amarshi Vaghadia All Responded
5 Sep 2013 East Midlands 1/1 responses
A community nurse administered anticoagulant despite patient bleeding, failed to share critical information with other professionals, and demonstrated a lack of professional insight and …
Leicestershire Partnership NHS Trust
Michael Irlam Historic (No Identified Response)
4 Sep 2013 North West 0/2 responses
A significant 24-day waiting time between discharge from crisis mental health services and the first follow-up appointment creates a dangerous gap in care, risking …
Improving Access to Psychological … Trafford Crisis Resolution and …
Karen Sutton All Responded
4 Sep 2013 East Midlands 1/1 responses
Hospital departments failed to share patient admission information, leading to discharge without prophylactic medication and inadequate follow-up arrangements due to a lack of Trust-wide …
University Hospitals Leicester NHS …
Jessica Ashton-Pyatt Historic (No Identified Response)
30 Aug 2013 East Midlands 0/1 responses
The emergency response was uncoordinated, lacked consultant leadership, and critical equipment like the defibrillator was uncharged with missing pads, compromising immediate patient care.
United Lincolnshire Hospitals NHS …
May Gibson Historic (No Identified Response)
30 Aug 2013 Yorkshire and the Humber 0/2 responses
The report identifies failures in obtaining and accounting for a community care assessment, performing pre-assessments, developing adequate care plans, conducting risk assessments, and implementing …
LNT Software Helios 47 Herries Lodge Care Home
Jack William Payton All Responded
30 Aug 2013 South West 1/1 responses
Control room staff's judgement and handling of the matter were negatively affected by excessive working hours and heavy caseloads, raising concerns about operational capacity.
Avon and Somerset Constabulary
Martin Leslie Brown Partially Responded
29 Aug 2013 South West 1/7 responses
The certificate for a road resurfacing product (Milepave) contained ambiguous wording regarding speed limit applicability and road types, risking its inappropriate use on unsuitable …
British Board of Agreement Fletcher's Solicitors Gloucestershire Constabulary
Dorothy Townley All Responded
28 Aug 2013 North West 1/2 responses
Significant communication breakdowns between District Nurses and the GP, inadequate burns treatment knowledge and training, and unclear procedures for urgent blood tests compromised patient …
Royal College of General … Royal College of Nursing
Terence O’Connell Partially Responded
28 Aug 2013 Wales 2/3 responses
A severe communication breakdown between the care home, district nurses, and out-of-hours GP led to the patient not being seen, alongside a lack of …
ABMU Health Board Grove Medical Centre Monkstone House Care Home