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 316 of 317
Showing 20 at a time
Date Report Region / area Addressee(s) Status Responses
27 Aug 2013 Muniza Mehrban
2013-0216 · Michael Singleton
This marks the fourth death in three years at the multi-storey car park due to individuals jumping, indicating an urgent need for …
North West
Blackburn, Hyndburn & Ribble Valley
 Jesta Capital Corporation Historic (No Identified Response) 0/1
23 Aug 2013 Jill Sinson
2013-0221 · Melanie Williamson
The GP failed to adequately monitor the deceased, prescribed large quantities of unsupervised medication despite a self-harm history, and staff neglected to …
Yorkshire and the Humber
West Yorkshire (East)
 Beeston Health Centre Historic (No Identified Response) 0/1
23 Aug 2013 Luna Lesko
2013-0214 · Andrew Harris
Delays in essential foetal monitoring and performing a Category 2 Caesarean section, coupled with insufficient out-of-hours theatre capacity, create a real risk …
London
London (Inner South)
 NHS Lewisham Commissioning Group University Hospital Lewisham Partially Responded 1/2
21 Aug 2013 John Walker
2013-0213 · Christopher Wilkinson
Insufficient risk care planning, lack of rationale for decreasing observation levels despite deteriorating mental state, and delays in reporting missing patients raised …
South East
West Sussex
 Sussex Partnership NHS Trust All Responded 1/1
20 Aug 2013 Ann Margaret Spearing
2013-0217 · T G Moore
Despite clear malnutrition and learning difficulties, the deceased was repeatedly assessed by mental health, hospital, and eating disorder services, yet consistently misdiagnosed …
South West
Avon
 Chair All Responded 1/1
20 Aug 2013 Derek Brierley
2013-0244 · Simon Nelson
The suprapubic procedure was performed by a consultant after a long hiatus with inadequate preparation, likely incorrect insertion, and a lack of …
North West
Manchester North
 England & Wales Pennine Acute Trust Partially Responded 1/2
20 Aug 2013 Mohammed Chaudhury
2013-0193 · Andrew Harris
The patient developed severe infected pressure sores due to the prolonged absence of an air mattress and insufficient turning, directly caused by …
London
London (Inner South)
 Care Quality Commission King’s College Hospitals NHS Foundation … Historic (No Identified Response) 0/2
20 Aug 2013 Nicola Matthews
2013-0192 · Dr R N Palmer
Incomplete documentation and unclear, undocumented follow-up arrangements for a high-risk patient discharged from inpatient care led to staff confusion and potential for …
London
London (South)
 South London and Maudsley NHS … Historic (No Identified Response) 0/1
16 Aug 2013 Sadie Ann Jane McGrady
2013-0189 · John Gittins
Substandard repairs to a Category D insurance write-off vehicle compromised its structural integrity, increasing injury risk in a collision, with no independent …
Wales
North Wales (East & Central)
 Driver and Vehicle Licensing Agency Association of British Insurers Vehicle and Operator Services Agency Partially Responded 2/3
16 Aug 2013 Keward Guy Domonic Harding
2013-0190 · Sheriff Payne
An urgent mental health assessment was significantly delayed for over two weeks, potentially preventing detection of a decline in physical health that …
South West
Dorset
 Community Mental Health Team Historic (No Identified Response) 0/1
15 Aug 2013 Ronald Ellwood
2013-0222 · Andrew Haigh
The provided concerns text is too truncated to identify specific safety issues.
West Midlands
Staffordshire (South)
 Queen’s Hospital All Responded 1/1
14 Aug 2013 Jordan Buckton
2013-0187 · Sheriff Payne
Prison staff lacked awareness of a prisoner's self-harm history due to information sharing failures. Additionally, there was inadequate follow-up after prescribing anti-depressants …
South West
Dorset
 Dorset Healthcare University NHS Foundation … National Offender Management Service Historic (No Identified Response) 0/2
13 Aug 2013 Vera Lillian Steel
2013-0185 · Michael Burgess
A frail, bedbound resident fatally burned herself while smoking. Care homes should be encouraged to provide fire-protective aprons or smocks to residents …
South East
Surrey
 Care Quality Commission South East England Fire and … Historic (No Identified Response) 0/2
9 Aug 2013 Ronald Sherlock
2013-0181 · William Armstrong
Older prisoners lacked appropriate access to speech and language therapists to assess and manage swallowing difficulties, including recommendations for diet and fluid …
East of England
Norfolk
 Serco Historic (No Identified Response) 0/1
8 Aug 2013 Dimitar Shtarbov
2013-0178 · Alexander R W Forrest
Seasonal agricultural workers lacked awareness of and access to GP and emergency services in the UK. Many also self-medicated with prescription-only medicines …
East Midlands
South Lincolnshire
 East Lincolnshire Clinical Commissioning Group South Lincolnshire Clinical Commissioning Group Historic (No Identified Response) 0/2
8 Aug 2013 Matthew Thomas Hamilton
2013-0180 · D L I Roberts
A narrow footpath lacked a barrier, allowing children to emerge suddenly into traffic, compounded by restricted vision from a fence and shrubbery.
North West
Cumbria (North & West)
 Cumbria County Council Historic (No Identified Response) 0/1
7 Aug 2013 Ethel Smith Leese
2013-0184 · Andrew Haigh
Chaotic address verification procedures by the hospital post-discharge led to significant issues with the monitoring of Mrs. Leese's warfarin levels after her …
West Midlands
South Staffordshire
 Stafford Hospital Historic (No Identified Response) 0/1
7 Aug 2013 Jean Miller
2013-0191 · Alison Mutch
District nurses failed to baseline a patient's wound, did not involve tissue viability specialists, and did not routinely take temperatures, as they …
North West
Manchester (West)
 Pennine Care Trust Historic (No Identified Response) 0/1
6 Aug 2013 Lucy Hannah Rose Bailey
2013-0176 · Robert Chapman
Concerns were raised regarding the adherence to or adequacy of guidelines for managing dystocia, which was identified as a known hazard.
East Midlands
Rutland & North Leicestershire
 JRCALC East Midlands Ambulance Service South Central Ambulance Service All Responded 1/3
5 Aug 2013 Alan Smith
2013-0173 · John Gittins
A co-worker lacked specific training for working at height, and generic risk assessment forms and method statements were not routinely used by …
Wales
North Wales (East & Central)
 Carrington Doors Historic (No Identified Response) 0/1
Muniza Mehrban Historic (No Identified Response)
27 Aug 2013 North West 0/1 responses
This marks the fourth death in three years at the multi-storey car park due to individuals jumping, indicating an urgent need for suicide prevention …
Jesta Capital Corporation
Jill Sinson Historic (No Identified Response)
23 Aug 2013 Yorkshire and the Humber 0/1 responses
The GP failed to adequately monitor the deceased, prescribed large quantities of unsupervised medication despite a self-harm history, and staff neglected to review critical …
Beeston Health Centre
Luna Lesko Partially Responded
23 Aug 2013 London 1/2 responses
Delays in essential foetal monitoring and performing a Category 2 Caesarean section, coupled with insufficient out-of-hours theatre capacity, create a real risk of preventable …
NHS Lewisham Commissioning Group University Hospital Lewisham
John Walker All Responded
21 Aug 2013 South East 1/1 responses
Insufficient risk care planning, lack of rationale for decreasing observation levels despite deteriorating mental state, and delays in reporting missing patients raised serious safety …
Sussex Partnership NHS Trust
Ann Margaret Spearing All Responded
20 Aug 2013 South West 1/1 responses
Despite clear malnutrition and learning difficulties, the deceased was repeatedly assessed by mental health, hospital, and eating disorder services, yet consistently misdiagnosed or found …
Chair
Derek Brierley Partially Responded
20 Aug 2013 North West 1/2 responses
The suprapubic procedure was performed by a consultant after a long hiatus with inadequate preparation, likely incorrect insertion, and a lack of Trust guidelines …
England & Wales Pennine Acute Trust
Mohammed Chaudhury Historic (No Identified Response)
20 Aug 2013 London 0/2 responses
The patient developed severe infected pressure sores due to the prolonged absence of an air mattress and insufficient turning, directly caused by nursing staff …
Care Quality Commission King’s College Hospitals NHS …
Nicola Matthews Historic (No Identified Response)
20 Aug 2013 London 0/1 responses
Incomplete documentation and unclear, undocumented follow-up arrangements for a high-risk patient discharged from inpatient care led to staff confusion and potential for future harm.
South London and Maudsley …
Sadie Ann Jane McGrady Partially Responded
16 Aug 2013 Wales 2/3 responses
Substandard repairs to a Category D insurance write-off vehicle compromised its structural integrity, increasing injury risk in a collision, with no independent checks for …
Driver and Vehicle Licensing … Association of British Insurers Vehicle and Operator Services …
Keward Guy Domonic Harding Historic (No Identified Response)
16 Aug 2013 South West 0/1 responses
An urgent mental health assessment was significantly delayed for over two weeks, potentially preventing detection of a decline in physical health that could have …
Community Mental Health Team
Ronald Ellwood All Responded
15 Aug 2013 West Midlands 1/1 responses
The provided concerns text is too truncated to identify specific safety issues.
Queen’s Hospital
Jordan Buckton Historic (No Identified Response)
14 Aug 2013 South West 0/2 responses
Prison staff lacked awareness of a prisoner's self-harm history due to information sharing failures. Additionally, there was inadequate follow-up after prescribing anti-depressants and a …
Dorset Healthcare University NHS … National Offender Management Service
Vera Lillian Steel Historic (No Identified Response)
13 Aug 2013 South East 0/2 responses
A frail, bedbound resident fatally burned herself while smoking. Care homes should be encouraged to provide fire-protective aprons or smocks to residents who smoke …
Care Quality Commission South East England Fire …
Ronald Sherlock Historic (No Identified Response)
9 Aug 2013 East of England 0/1 responses
Older prisoners lacked appropriate access to speech and language therapists to assess and manage swallowing difficulties, including recommendations for diet and fluid intake.
Serco
Dimitar Shtarbov Historic (No Identified Response)
8 Aug 2013 East Midlands 0/2 responses
Seasonal agricultural workers lacked awareness of and access to GP and emergency services in the UK. Many also self-medicated with prescription-only medicines obtained from …
East Lincolnshire Clinical Commissioning … South Lincolnshire Clinical Commissioning …
Matthew Thomas Hamilton Historic (No Identified Response)
8 Aug 2013 North West 0/1 responses
A narrow footpath lacked a barrier, allowing children to emerge suddenly into traffic, compounded by restricted vision from a fence and shrubbery.
Cumbria County Council
Ethel Smith Leese Historic (No Identified Response)
7 Aug 2013 West Midlands 0/1 responses
Chaotic address verification procedures by the hospital post-discharge led to significant issues with the monitoring of Mrs. Leese's warfarin levels after her move to …
Stafford Hospital
Jean Miller Historic (No Identified Response)
7 Aug 2013 North West 0/1 responses
District nurses failed to baseline a patient's wound, did not involve tissue viability specialists, and did not routinely take temperatures, as they were not …
Pennine Care Trust
Lucy Hannah Rose Bailey All Responded
6 Aug 2013 East Midlands 1/3 responses
Concerns were raised regarding the adherence to or adequacy of guidelines for managing dystocia, which was identified as a known hazard.
JRCALC East Midlands Ambulance Service South Central Ambulance Service
Alan Smith Historic (No Identified Response)
5 Aug 2013 Wales 0/1 responses
A co-worker lacked specific training for working at height, and generic risk assessment forms and method statements were not routinely used by employees.
Carrington Doors