Coroner reports

Articles in this category

1. The Preventable Deaths Tracker: a presentation by Dr Georgia Richards

   • Coroner reports
   • Data

   By Patient_Safety_Learning, 5 hours ago

   • 0 comments
   • 10 views
   • 
   • Added by Patient_Safety_Learning
   • 5 hours ago

2. Prevention of Future Deaths report: Lyn Brind (18 January 2023)

   • Coroner
   • Coroner reports
   • (and 5 more)

     Tagged with:

     • Coroner
     • Coroner reports
     • Long waiting list
     • Lack of resources
     • Emergency medicine
     • Patient death
     • Heart disease

   By Patient Safety Learning, 17 February

   • 0 comments
   • 63 views
   • 
   • Added by Patient Safety Learning
   • 17 February

3. Prevention of future deaths report: Yvonne Eaves (1 April 2022)

   • Coroner reports
   • Mental health
   • (and 5 more)

     Tagged with:

     • Coroner reports
     • Mental health
     • Patient death
     • Mental health unit
     • Risk assessment
     • Medication
     • Policies / Protocols / Procedures

   By Patient-Safety-Learning, 27 January

   • 0 comments
   • 94 views
   • 
   • Added by Patient-Safety-Learning
   • 27 January

4. Prevention of Future Deaths: Hayley Smith (4 January 2023)

   • Coroner
   • Coroner reports
   • (and 5 more)

     Tagged with:

     • Coroner
     • Coroner reports
     • Eating disorder
     • Communication
     • Information sharing
     • Communication problems
     • Organisation / service factors

   By Patient Safety Learning, 9 January

   • 0 comments
   • 115 views
   • 
   • Added by Patient Safety Learning
   • 9 January

5. Ben King: Prevention of future deaths report (20 July 2021)

   • Coroner
   • Coroner reports
   • (and 5 more)

     Tagged with:

     • Coroner
     • Coroner reports
     • Learning disabilities
     • Mental health unit
     • Medicine - Respiratory
     • Patient death
     • Obesity

   By Patient-Safety-Learning, 29 December, 2022

   • 0 comments
   • 62 views
   • 
   • Added by Patient-Safety-Learning
   • 29 December, 2022

6. Prevention of future deaths report: Jonathan Kingsman (13 July 2021)

   • Coroner reports
   • Coroner
   • (and 5 more)

     Tagged with:

     • Coroner reports
     • Coroner
     • Deep vein thrombosis
     • Risk assessment
     • Decision making
     • Patient death
     • Mental health unit

   By Patient-Safety-Learning, 27 December, 2022

   • 0 comments
   • 50 views
   • 
   • Added by Patient-Safety-Learning
   • 27 December, 2022

7. Prevention of Future Deaths report: Quinn Parker (21 November 2022)

   • Baby
   • Patient death
   • (and 7 more)

     Tagged with:

     • Baby
     • Patient death
     • Investigation
     • Maternity
     • Organisation / service factors
     • Coroner
     • Coroner reports
     • Labour
     • Pathology

   By Patient Safety Learning, 15 December, 2022

   • 0 comments
   • 122 views
   • 
   • Added by Patient Safety Learning
   • 15 December, 2022

8. Prevention of Future Deaths Report: Celia Marsh (21 November 2022)

   • Coroner
   • Coroner reports
   • (and 2 more)

     Tagged with:

     • Coroner
     • Coroner reports
     • Allergies
     • Patient death

   By Patient Safety Learning, 6 December, 2022

   • 0 comments
   • 123 views
   • 
   • Added by Patient Safety Learning
   • 6 December, 2022

9. Prevention of Future Deaths Report: Karen Starling and Anne Martinez (21 November 2022)

   • Coroner
   • Coroner reports
   • (and 7 more)

     Tagged with:

     • Coroner
     • Coroner reports
     • Patient death
     • Organisation / service factors
     • Healthcare associated infection
     • Physical environment
     • Infection control
     • High risk groups
     • Infrastructure / building / equipment

   By Patient Safety Learning, 22 November, 2022

   • 0 comments
   • 211 views
   • 
   • Added by Patient Safety Learning
   • 22 November, 2022

10. Prevention of Future Deaths Report: Asher Sinclair (4 September 2022)

    • Coroner
    • Coroner reports
    • (and 7 more)

      Tagged with:

      • Coroner
      • Coroner reports
      • Investigation
      • Children and Young People
      • Staff factors
      • Skills gap
      • Training
      • Care plan
      • Near miss

    By Patient Safety Learning, 7 October, 2022

    • 0 comments
    • 349 views
    • 
    • Added by Patient Safety Learning
    • 7 October, 2022

11. Prevention of Future Deaths Report: Eliot Harris (3 October 2022)

    • Coroner
    • Coroner reports
    • (and 9 more)

      Tagged with:

      • Coroner
      • Coroner reports
      • Recommendations
      • Training
      • Staff factors
      • More staff training
      • Mental health
      • Patient death
      • Schizophrenia
      • Observations
      • Care plan

    By Patient Safety Learning, 6 October, 2022

    • 0 comments
    • 197 views
    • 
    • Added by Patient Safety Learning
    • 6 October, 2022

12. Prevention of Future Deaths Report: Martha Mills (28 February 2022)

    • Coroner
    • Coroner reports
    • (and 12 more)

      Tagged with:

      • Coroner
      • Coroner reports
      • Investigation
      • Children and Young People
      • Patient death
      • Organisational culture
      • Organisational learning
      • Staff factors
      • Hierarchy
      • Sepsis
      • Monitoring
      • Paediatrics
      • Medicine - Hepatology
      • Communication problems

    By Patient Safety Learning, 5 September, 2022

    • 0 comments
    • 1,082 views
    • 
    • Added by Patient Safety Learning
    • 5 September, 2022

13. Prevention of Future Deaths report: Sarah Dunn (12 May 2022)

    • Coroner
    • Coroner reports
    • (and 6 more)

      Tagged with:

      • Coroner
      • Coroner reports
      • Pregnancy
      • Sepsis
      • Patient death
      • Staff factors
      • Training
      • Skills gap

    By Patient Safety Learning, 19 May, 2022

    • 0 comments
    • 432 views
    • 
    • Added by Patient Safety Learning
    • 19 May, 2022

14. Prevention of Future Deaths report: Matthew Caseby (27 April 2022)

    • Coroner
    • Coroner reports
    • (and 9 more)

      Tagged with:

      • Coroner
      • Coroner reports
      • Policies
      • Risk assessment
      • Physical environment
      • Mental health unit
      • Private sector
      • Patient death
      • Investigation
      • Organisation / service factors
      • Observations

    By Patient Safety Learning, 29 April, 2022

    • 0 comments
    • 545 views
    • 
    • Added by Patient Safety Learning
    • 29 April, 2022

15. Prevention of Future Deaths report: Shaun Mansell (1 November 2021)

    • Coroner
    • Coroner reports
    • (and 7 more)

      Tagged with:

      • Coroner
      • Coroner reports
      • Ambulance
      • Lack of resources
      • Patient death
      • Substance / Drug abuse
      • Long waiting list
      • Training
      • Skills gap

    By Patient Safety Learning, 13 April, 2022

    • 0 comments
    • 417 views
    • 
    • Added by Patient Safety Learning
    • 13 April, 2022

16. Preventable deaths tracker

    • Patient death
    • Coroner reports
    • (and 2 more)

      Tagged with:

      • Patient death
      • Coroner reports
      • Investigation
      • Database

    By Patient-Safety-Learning, 28 March, 2022

    • 0 comments
    • 664 views
    • 
    • Added by Patient-Safety-Learning
    • 28 March, 2022

17. Royal College of Anaesthetists - Prevention of future deaths webpage

    • Anaesthesia
    • Anaesthetist
    • (and 3 more)

      Tagged with:

      • Anaesthesia
      • Anaesthetist
      • Patient death
      • Training
      • Policies / Protocols / Procedures

    By Patient-Safety-Learning, 16 March, 2022

    • 0 comments
    • 465 views
    • 
    • Added by Patient-Safety-Learning
    • 16 March, 2022

18. Prevention of Future Deaths report – Van Tuyen (22 February 2022)

    • Never event
    • Patient death
    • (and 3 more)

      Tagged with:

      • Never event
      • Patient death
      • Nutrition
      • Medical device / equipment
      • Adminstering medication

    By Mark Hughes, 15 March, 2022

    • 1 comment
    • 855 views
    • 
    • Comment by Patient-Safety-Learning
    • 15 March, 2022

19. Prevention of Future Deaths report – Chloe Lumb (17 February 2022)

    • Medicine - Cardiology
    • Diagnosis
    • (and 3 more)

      Tagged with:

      • Medicine - Cardiology
      • Diagnosis
      • Patient death
      • Accident and Emergency
      • Emergency medicine

    By Mark Hughes, 14 March, 2022

    • 0 comments
    • 843 views
    • 
    • Added by Mark Hughes
    • 14 March, 2022

20. Learning from Coroner's reports

    • Coroner reports
    • Coroner
    • (and 4 more)

      Tagged with:

      • Coroner reports
      • Coroner
      • Patient death
      • Reporting
      • Organisational learning
      • Staff factors

    By Patient Safety Learning, 14 March, 2022

    • 1 comment
    • 1,619 views
    • 
    • Comment by Steve Turner
    • 15 March, 2022

21. Prevention of Future Deaths report - Sky Rollings (16 October 2021)

    • Patient death
    • Children and Young People
    • (and 2 more)

      Tagged with:

      • Patient death
      • Children and Young People
      • Mental health - CAMHS
      • Mental health

    By Patient-Safety-Learning, 7 March, 2022

    • 0 comments
    • 490 views
    • 
    • Added by Patient-Safety-Learning
    • 7 March, 2022

22. Prevention of Future Deaths report - Samantha Gould (28 May 2021)

    • Patient death
    • Mental health - CAMHS
    • (and 4 more)

      Tagged with:

      • Patient death
      • Mental health - CAMHS
      • Mental health
      • Self harm/ suicide
      • Medication
      • Pharmacist

    By Patient-Safety-Learning, 1 March, 2022

    • 0 comments
    • 461 views
    • 
    • Added by Patient-Safety-Learning
    • 1 March, 2022

23. Prevention of Future Deaths report – Daniel France (16 February 2022)

    • Self harm/ suicide
    • Mental health
    • (and 8 more)

      Tagged with:

      • Self harm/ suicide
      • Mental health
      • Patient death
      • Coroner
      • Coroner reports
      • Care coordination
      • Risk management
      • Young Adult
      • Mental health - CAMHS
      • LGBTQI

    By Patient Safety Learning, 25 February, 2022

    • 0 comments
    • 803 views
    • 
    • Added by Patient Safety Learning
    • 25 February, 2022

24. Prevention of Future Deaths report – Benjamin Stroud (8 February 2022)

    • Coroner reports
    • Coroner
    • (and 6 more)

      Tagged with:

      • Coroner reports
      • Coroner
      • Mental health
      • Mental health unit
      • Psychosis
      • Patient death
      • Medication
      • Care coordination

    By Patient Safety Learning, 17 February, 2022

    • 0 comments
    • 841 views
    • 
    • Added by Patient Safety Learning
    • 17 February, 2022

25. Prevention of Future Deaths report – Barbara Young (28 January 2022)

    • Patient death
    • Coroner reports
    • (and 4 more)

      Tagged with:

      • Patient death
      • Coroner reports
      • Ambulance
      • Pneumonia
      • Falls
      • Older People (over 65)

    By Patient-Safety-Learning, 15 February, 2022

    • 0 comments
    • 639 views
    • 
    • Added by Patient-Safety-Learning
    • 15 February, 2022