Coroner reports

Articles in this category

1. Prevention of Future Deaths Report: Samuel Brookes (23 April 2025)

   • Patient death
   • Discharge
   • (and 4 more)

     Tagged with:

     • Patient death
     • Discharge
     • Post-discharge support
     • Handover
     • Coroner reports
     • Coroner

   By Mark Hughes, 28 April, 2025

   • 0 comments
   • 523 views
   • 
   • Added by Mark Hughes
   • 28 April, 2025

2. Prevention of Future Deaths Report: Ida Lock (26 March 2025)

   • Coroner
   • Coroner reports
   • (and 10 more)

     Tagged with:

     • Coroner
     • Coroner reports
     • Patient death
     • Duty of Candour
     • Organisational culture
     • Maternity
     • Staff factors
     • Skill-based issue
     • Training
     • Midwife
     • Investigation
     • Transparency

   By Patient Safety Learning, 28 March, 2025

   • 0 comments
   • 688 views
   • 
   • Added by Patient Safety Learning
   • 28 March, 2025

3. Prevention of Future Deaths Report: Billie Wick (17 March 2025)

   • Coroner
   • Coroner reports
   • (and 9 more)

     Tagged with:

     • Coroner
     • Coroner reports
     • Adolescent
     • Patient death
     • Asthma
     • Monitoring
     • Observations
     • Additional staff required
     • Lack of resources
     • Discharge
     • Investigation

   By Patient Safety Learning, 18 March, 2025

   • 0 comments
   • 506 views
   • 
   • Added by Patient Safety Learning
   • 18 March, 2025

4. Early Day Motion - National oversight mechanism (27 February 2025)

   • Coroner
   • Coroner reports
   • (and 3 more)

     Tagged with:

     • Coroner
     • Coroner reports
     • Recommendations
     • Implementation
     • Patient death

   By Mark Hughes, 4 March, 2025

   • 0 comments
   • 445 views
   • 
   • Added by Mark Hughes
   • 4 March, 2025

5. Prevention of Future Deaths Report: Pamela Marking (24 February 2025)

   • Coroner
   • Coroner reports
   • (and 5 more)

     Tagged with:

     • Coroner
     • Coroner reports
     • Patient death
     • Recommendations
     • Investigation
     • Physician associate
     • Skill-based issue

   By Sam, 28 February, 2025

   • 0 comments
   • 893 views
   • 
   • Added by Sam
   • 28 February, 2025

6. Prevention of Future Deaths Report: Thomas Kingston (9 January 2025)

   • Medication
   • Depression
   • (and 5 more)

     Tagged with:

     • Medication
     • Depression
     • Self harm/ suicide
     • Coroner reports
     • Coroner
     • Adverse reaction
     • Communication

   By Patient Safety Learning, 4 February, 2025

   • 0 comments
   • 742 views
   • 
   • Added by Patient Safety Learning
   • 4 February, 2025

7. Prevention of Future Deaths Report: Matthew Sheldrick (19 December 2024)

   • Coroner
   • Coroner reports
   • (and 12 more)

     Tagged with:

     • Coroner
     • Coroner reports
     • Self harm/ suicide
     • Patient death
     • Patient / family involvement
     • Investigation
     • Mental health
     • Physical environment
     • Lack of resources
     • ADHD
     • Autism
     • LGBTQI
     • Integrated Care Board (ICB)
     • Communication problems

   By Patient Safety Learning, 28 January, 2025

   • 0 comments
   • 373 views
   • 
   • Added by Patient Safety Learning
   • 28 January, 2025

8. Prevention of Future Deaths report: Sheila Wexler (16 January 2025)

   • Coroner
   • Coroner reports
   • (and 3 more)

     Tagged with:

     • Coroner
     • Coroner reports
     • Ulcers / pressure sores
     • Medical device / equipment
     • Patient death

   By Patient Safety Learning, 22 January, 2025

   • 0 comments
   • 943 views
   • 
   • Added by Patient Safety Learning
   • 22 January, 2025

9. Prevention of future deaths report: Harry Vass (13 June 2024)

   • Coroner reports
   • Mental health
   • (and 6 more)

     Tagged with:

     • Coroner reports
     • Mental health
     • Young Adult
     • Monitoring
     • Observations
     • Accident and Emergency
     • Police
     • Investigation

   By Patient_Safety_Learning, 20 January, 2025

   • 0 comments
   • 501 views
   • 
   • Added by Patient_Safety_Learning
   • 20 January, 2025

10. Prevention of Future Deaths Report: James Alderman (28 December 2024)

    • Baby
    • Patient death
    • (and 7 more)

      Tagged with:

      • Baby
      • Patient death
      • Nutrition
      • Coroner
      • Coroner reports
      • Advice
      • Paediatrics
      • Standards
      • Maternity

    By Patient Safety Learning, 2 January, 2025

    • 0 comments
    • 1,141 views
    • 
    • Added by Patient Safety Learning
    • 2 January, 2025

11. Prevention of Future Deaths Report: Susan Evans (13 December 2024)

    • Coroner
    • Coroner reports
    • (and 6 more)

      Tagged with:

      • Coroner
      • Coroner reports
      • Obesity
      • Surgery - General
      • Policies
      • Staff factors
      • Skills
      • Patient death

    By Patient Safety Learning, 2 January, 2025

    • 0 comments
    • 523 views
    • 
    • Added by Patient Safety Learning
    • 2 January, 2025

12. Prevention of Future Deaths Report: Declan Morrison (24 October 2024)

    • Coroner
    • Coroner reports
    • (and 5 more)

      Tagged with:

      • Coroner
      • Coroner reports
      • Investigation
      • Patient death
      • Autism
      • Mental health
      • Organisation / service factors

    By Patient Safety Learning, 11 December, 2024

    • 0 comments
    • 625 views
    • 
    • Added by Patient Safety Learning
    • 11 December, 2024

13. Neglect contributed to the death of nine-year-old Dylan Cope, an inquest finds (24 May, 2024)

    • Coroner reports
    • Sepsis
    • (and 1 more)

      Tagged with:

      • Coroner reports
      • Sepsis
      • Children and Young People

    By Patient_Safety_Learning, 18 November, 2024

    • 0 comments
    • 534 views
    • 
    • Added by Patient_Safety_Learning
    • 18 November, 2024

14. Prevention of future deaths report: David Strachan (27 February 2023)

    • Coroner reports
    • Coroner
    • (and 7 more)

      Tagged with:

      • Coroner reports
      • Coroner
      • Patient death
      • Ambulance
      • Lack of resources
      • Handover
      • Care assessment
      • Wales
      • Organisation / service factors

    By Patient Safety Learning, 12 November, 2024

    • 0 comments
    • 392 views
    • 
    • Added by Patient Safety Learning
    • 12 November, 2024

15. Prevention of Future Deaths report: Tamara Davis (15 October 2024)

    • Coroner
    • Coroner reports
    • (and 4 more)

      Tagged with:

      • Coroner
      • Coroner reports
      • Patient death
      • Sepsis
      • Lack of resources
      • Organisation / service factors

    By Patient Safety Learning, 21 October, 2024

    • 0 comments
    • 627 views
    • 
    • Added by Patient Safety Learning
    • 21 October, 2024

16. Prevention of Future Deaths report: Sewa Chaddha (15 October 2024)

    • Human factors
    • Medication
    • (and 7 more)

      Tagged with:

      • Human factors
      • Medication
      • Packaging/ labelling/ signage
      • Patient death
      • Older People (over 65)
      • Coroner
      • Coroner reports
      • Pharmacy / chemist
      • Home

    By Patient Safety Learning, 16 October, 2024

    • 0 comments
    • 722 views
    • 
    • Added by Patient Safety Learning
    • 16 October, 2024

17. Editorial: The Guardian view on the coroner’s role: if deaths can be prevented, they should be (8 October 2024)

    • Coroner
    • Coroner reports
    • (and 3 more)

      Tagged with:

      • Coroner
      • Coroner reports
      • Organisational learning
      • Investigation
      • Patient death

    By Patient Safety Learning, 15 October, 2024

    • 0 comments
    • 386 views
    • 
    • Added by Patient Safety Learning
    • 15 October, 2024

18. Prevent of Future Deaths report: Nigel Hammond (9 October 2024)

    • Coroner
    • Coroner reports
    • (and 4 more)

      Tagged with:

      • Coroner
      • Coroner reports
      • Self harm/ suicide
      • Mental health
      • Care coordination
      • Patient death

    By Patient Safety Learning, 11 October, 2024

    • 0 comments
    • 519 views
    • 
    • Added by Patient Safety Learning
    • 11 October, 2024

19. Prevention of Future Deaths Report: Rachel Gibson (2 September 2024)

    • Coroner
    • Coroner reports
    • (and 6 more)

      Tagged with:

      • Coroner
      • Coroner reports
      • Investigation
      • Anaesthesia
      • Human factors
      • Human error
      • Packaging/ labelling/ signage
      • Patient death

    By Patient Safety Learning, 3 September, 2024

    • 0 comments
    • 1,318 views
    • 
    • Added by Patient Safety Learning
    • 3 September, 2024

20. Prevention of Future Deaths report: Juliette Sewell (19 August 2024)

    • Mental health
    • Patient death
    • (and 8 more)

      Tagged with:

      • Mental health
      • Patient death
      • Follow up
      • Appointment
      • Coroner
      • Coroner reports
      • Investigation
      • Self harm/ suicide
      • Additional staff required
      • Care record

    By Patient Safety Learning, 21 August, 2024

    • 0 comments
    • 1,006 views
    • 
    • Added by Patient Safety Learning
    • 21 August, 2024

21. Prevention of future deaths report: Susan Pollitt (8 August 2024)

    • Acute kidney injury
    • Patient death
    • (and 1 more)

      Tagged with:

      • Acute kidney injury
      • Patient death
      • Physician associate

    By Mark Hughes, 12 August, 2024

    • 0 comments
    • 1,369 views
    • 
    • Added by Mark Hughes
    • 12 August, 2024

22. Prevention of future deaths report: Mahamoud Ali (31 July 2024)

    • Mental health
    • Investigation
    • (and 3 more)

      Tagged with:

      • Mental health
      • Investigation
      • Observations
      • Patient death
      • Falls

    By Mark Hughes, 8 August, 2024

    • 1 comment
    • 684 views
    • 
    • Comment by Marcus Ineson
    • 8 August, 2024

23. Prevention of future deaths report: Anoush Summers (14 June 2024)

    • Digital health
    • Wearables
    • (and 7 more)

      Tagged with:

      • Digital health
      • Wearables
      • Coroner
      • Coroner reports
      • Patient death
      • Falls
      • Older People (over 65)
      • Carer
      • Community care

    By Patient Safety Learning, 27 June, 2024

    • 0 comments
    • 501 views
    • 
    • Added by Patient Safety Learning
    • 27 June, 2024

24. Prevention of future deaths report: Bobilya Mulonge (14 May 2024)

    • Investigation
    • Coroner reports
    • (and 6 more)

      Tagged with:

      • Investigation
      • Coroner reports
      • Coroner
      • Accident and Emergency
      • Lack of resources
      • Handover
      • Patient death
      • Ambulance

    By Patient Safety Learning, 25 June, 2024

    • 0 comments
    • 472 views
    • 
    • Added by Patient Safety Learning
    • 25 June, 2024

25. Prevention of future death report: Winbourne Charles (5 May 2024)

    • Coroner reports
    • Coroner
    • (and 8 more)

      Tagged with:

      • Coroner reports
      • Coroner
      • Self harm/ suicide
      • Risk assessment
      • Observations
      • Care record
      • Staff factors
      • Investigation
      • Mental health
      • Organisational culture

    By Patient Safety Learning, 14 June, 2024

    • 0 comments
    • 872 views
    • 
    • Added by Patient Safety Learning
    • 14 June, 2024