Coroner reports

Articles in this category

1. Prevention of future deaths report: Christine Booker (31 May 2024)

   • Patient death
   • Organisation / service factors
   • (and 4 more)

     Tagged with:

     • Patient death
     • Organisation / service factors
     • Care coordination
     • Coroner reports
     • Coroner
     • Transfer of care

   By Patient Safety Learning, 10 June, 2024

   • 0 comments
   • 743 views
   • 
   • Added by Patient Safety Learning
   • 10 June, 2024

2. Prevention of Future Deaths Report: Kerri Mothersole (28 February 2024)

   • Coroner reports
   • Coroner
   • (and 4 more)

     Tagged with:

     • Coroner reports
     • Coroner
     • Cancer
     • Diagnostic error
     • Diagnosis
     • WPSD24

   By Patient-Safety-Learning, 16 May, 2024

   • 0 comments
   • 566 views
   • 
   • Added by Patient-Safety-Learning
   • 16 May, 2024

3. Prevention of Future Deaths report: Finlay Finlayson (25 March 2024)

   • Coroner reports
   • Coroner
   • (and 4 more)

     Tagged with:

     • Coroner reports
     • Coroner
     • Prison
     • Electronic Health Record
     • Patient death
     • Communication

   By Patient Safety Learning, 23 April, 2024

   • 0 comments
   • 559 views
   • 
   • Added by Patient Safety Learning
   • 23 April, 2024

4. Prevention of Future Deaths Report: Tommy Gillman (15 April 2024)

   • Patient death
   • Sepsis
   • (and 8 more)

     Tagged with:

     • Patient death
     • Sepsis
     • Coroner
     • Coroner reports
     • Baby
     • Handover
     • Paediatrics
     • Additional staff required
     • Staff factors
     • Emergency medicine

   By Patient Safety Learning, 17 April, 2024

   • 0 comments
   • 661 views
   • 
   • Added by Patient Safety Learning
   • 17 April, 2024

5. Dr Georgia Richards/Preventable Deaths Tracker evidence at the Coroner Service inquiry - variation (February 2024)

   • Coroner reports
   • Coroner
   • (and 1 more)

     Tagged with:

     • Coroner reports
     • Coroner
     • Patient death

   By Patient_Safety_Learning, 4 March, 2024

   • 0 comments
   • 707 views
   • 
   • Added by Patient_Safety_Learning
   • 4 March, 2024

6. Prevention of future deaths report: Nicolas Gerasimidis (12 February 2024)

   • Patient death
   • Mental health
   • (and 10 more)

     Tagged with:

     • Patient death
     • Mental health
     • Organisation / service factors
     • Coroner
     • Coroner reports
     • Lack of resources
     • Workforce management
     • Additional staff required
     • Community care
     • Care coordination
     • Anxiety
     • Self harm/ suicide

   By Patient Safety Learning, 27 February, 2024

   • 0 comments
   • 565 views
   • 
   • Added by Patient Safety Learning
   • 27 February, 2024

7. Prevention of Future Deaths report: Emily Harkleroad (21 February 2024)

   • Coroner reports
   • Coroner
   • (and 5 more)

     Tagged with:

     • Coroner reports
     • Coroner
     • Patient death
     • Electronic Health Record
     • Care record
     • System safety
     • Accident and Emergency

   By Patient Safety Learning, 26 February, 2024

   • 0 comments
   • 1,084 views
   • 
   • Added by Patient Safety Learning
   • 26 February, 2024

8. Prevention of Future Deaths report: Shahzadi Khan (31 January 2024)

   • Coroner
   • Coroner reports
   • (and 7 more)

     Tagged with:

     • Coroner
     • Coroner reports
     • Mental health
     • Self harm/ suicide
     • Patient death
     • Patient / family involvement
     • Care coordination
     • Medication
     • Lack of resources

   By Patient Safety Learning, 19 February, 2024

   • 0 comments
   • 1,007 views
   • 
   • Added by Patient Safety Learning
   • 19 February, 2024

9. Five recommendations to prevent future deaths: Written evidence for the Parliamentary follow-up Inquiry to The Coroner Service (Georgia Richards, 9 February 2024)

   • Coroner
   • Coroner reports
   • (and 2 more)

     Tagged with:

     • Coroner
     • Coroner reports
     • Patient death
     • Consultation

   By Patient Safety Learning, 12 February, 2024

   • 1 comment
   • 1,528 views
   • 
   • Comment by Joy Ford
   • 5 April, 2024

10. Prevention of Future Deaths report: Thomas Ithell (25 January 2024)

    • Patient death
    • Coroner reports
    • (and 6 more)

      Tagged with:

      • Patient death
      • Coroner reports
      • Coroner
      • Cancer
      • Reporting
      • Follow up
      • Tests / investigations
      • Clinical governance

    By Patient Safety Learning, 30 January, 2024

    • 0 comments
    • 495 views
    • 
    • Added by Patient Safety Learning
    • 30 January, 2024

11. National Coronial Information System (Australia and New Zealand)

    • Australia
    • Coroner
    • (and 5 more)

      Tagged with:

      • Australia
      • Coroner
      • Coroner reports
      • Patient death
      • Database
      • Investigation
      • Information sharing

    By Patient Safety Learning, 26 January, 2024

    • 0 comments
    • 1,160 views
    • 
    • Added by Patient Safety Learning
    • 26 January, 2024

12. Prevention of Future Deaths report: Dennis King (19 January 2024)

    • Patient death
    • Coroner
    • (and 6 more)

      Tagged with:

      • Patient death
      • Coroner
      • Coroner reports
      • Ambulance
      • Accident and Emergency
      • Lack of resources
      • Organisation / service factors
      • Transfer of care

    By Patient Safety Learning, 23 January, 2024

    • 0 comments
    • 781 views
    • 
    • Added by Patient Safety Learning
    • 23 January, 2024

13. Prevention of Future Deaths report: Elizabeth Roberts (8 January 2024)

    • Coroner
    • Coroner reports
    • (and 3 more)

      Tagged with:

      • Coroner
      • Coroner reports
      • Patient death
      • Community care
      • Lack of resources

    By Mark Hughes, 22 January, 2024

    • 0 comments
    • 845 views
    • 
    • Added by Mark Hughes
    • 22 January, 2024

14. The Law Society Gazette: A postcode lottery for the bereaved (12 January 2024)

    • Coroner
    • Patient death
    • (and 3 more)

      Tagged with:

      • Coroner
      • Patient death
      • Investigation
      • Patient / family involvement
      • Coroner reports

    By Patient Safety Learning, 17 January, 2024

    • 0 comments
    • 737 views
    • 
    • Added by Patient Safety Learning
    • 17 January, 2024

15. Prevention of Future Deaths report: Morgan-Rose Hart (28 December 2023)

    • Coroner
    • Coroner reports
    • (and 5 more)

      Tagged with:

      • Coroner
      • Coroner reports
      • Patient death
      • Mental health
      • ADHD
      • Autism
      • Self harm/ suicide

    By Mark Hughes, 9 January, 2024

    • 0 comments
    • 1,636 views
    • 
    • Added by Mark Hughes
    • 9 January, 2024

16. Prevention of Future Deaths report: Andrew Guillaume (3 January 2024)

    • Coroner
    • Coroner reports
    • (and 4 more)

      Tagged with:

      • Coroner
      • Coroner reports
      • Patient death
      • Transfer of care
      • Medicine - Cardiology
      • Surgery - Cardiothoracic

    By Mark Hughes, 5 January, 2024

    • 0 comments
    • 745 views
    • 
    • Added by Mark Hughes
    • 5 January, 2024

17. Prevention of Future Deaths report: Susan Gladstone (1 December 2023)

    • Patient death
    • Coroner
    • (and 4 more)

      Tagged with:

      • Patient death
      • Coroner
      • Coroner reports
      • Prescribing
      • Medication
      • Adminstering medication

    By Patient Safety Learning, 19 December, 2023

    • 0 comments
    • 979 views
    • 
    • Added by Patient Safety Learning
    • 19 December, 2023

18. Prevention of future deaths report: Philip Malone (29 November 2023)

    • Coroner
    • Coroner reports
    • (and 6 more)

      Tagged with:

      • Coroner
      • Coroner reports
      • Patient death
      • Mental health
      • Self harm/ suicide
      • Organisation / service factors
      • Lack of resources
      • Schizophrenia

    By Patient Safety Learning, 6 December, 2023

    • 0 comments
    • 834 views
    • 
    • Added by Patient Safety Learning
    • 6 December, 2023

19. Prevention of Future Deaths report: Peter Fleming (18 July 2023)

    • Patient death
    • Coroner
    • (and 5 more)

      Tagged with:

      • Patient death
      • Coroner
      • Coroner reports
      • Mental health
      • Self harm/ suicide
      • Organisation / service factors
      • Lack of resources

    By Patient Safety Learning, 2 December, 2023

    • 0 comments
    • 804 views
    • 
    • Added by Patient Safety Learning
    • 2 December, 2023

20. Prevention of Future Deaths report: Christina Ruse (3 October 2022)

    • Coroner
    • Coroner reports
    • (and 6 more)

      Tagged with:

      • Coroner
      • Coroner reports
      • Patient death
      • Recommendations
      • Ambulance
      • Emergency medicine
      • Private sector
      • Transfer of care

    By Mark Hughes, 14 November, 2023

    • 0 comments
    • 699 views
    • 
    • Added by Mark Hughes
    • 14 November, 2023

21. Prevention of Future Deaths report: Barbara Hollis (3 October 2022)

    • Coroner
    • Coroner reports
    • (and 6 more)

      Tagged with:

      • Coroner
      • Coroner reports
      • Patient death
      • Recommendations
      • Ambulance
      • Emergency medicine
      • Private sector
      • Transfer of care

    By Mark Hughes, 14 November, 2023

    • 0 comments
    • 744 views
    • 
    • Added by Mark Hughes
    • 14 November, 2023

22. “More than a paper exercise” – Enhancing the impact of Prevention of Future Death Reports (Independent Advisory Panel on Deaths in Custody, September 2023)

    • Coroner reports
    • Patient death
    • (and 3 more)

      Tagged with:

      • Coroner reports
      • Patient death
      • Organisational learning
      • Risk management
      • Prison

    By Patient_Safety_Learning, 7 November, 2023

    • 0 comments
    • 787 views
    • 
    • Added by Patient_Safety_Learning
    • 7 November, 2023

23. Prevention of Future Deaths report: Geoffrey Whatling (6 November 2023)

    • Patient death
    • Coroner
    • (and 3 more)

      Tagged with:

      • Patient death
      • Coroner
      • Care home
      • Deterioration
      • Monitoring

    By Mark Hughes, 6 November, 2023

    • 0 comments
    • 814 views
    • 
    • Added by Mark Hughes
    • 6 November, 2023

24. Tracking deaths, part 3: Patient Safety

    • Coroner reports
    • Patient death

    By Patient_Safety_Learning, 2 October, 2023

    • 0 comments
    • 490 views
    • 
    • Added by Patient_Safety_Learning
    • 2 October, 2023

25. Prevention of Future Deaths report: Harold Pedley (8 September 2023)

    • Patient death
    • Coroner
    • (and 7 more)

      Tagged with:

      • Patient death
      • Coroner
      • Coroner reports
      • Organisational Performance
      • Lack of resources
      • Additional staff required
      • Older People (over 65)
      • Staff factors
      • Emergency medicine

    By Patient Safety Learning, 28 September, 2023

    • 0 comments
    • 665 views
    • 
    • Added by Patient Safety Learning
    • 28 September, 2023