Coroner reports

Articles in this category

1. Prevention of Future Deaths report: Geoffrey Hoad (13 September 2023)

   • Coroner
   • Coroner reports
   • (and 6 more)

     Tagged with:

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

   By Patient Safety Learning, 26 September, 2023

   • 0 comments
   • 1,116 views
   • 
   • Added by Patient Safety Learning
   • 26 September, 2023

2. A systematic narrative review of coroners’ Prevention of Future Deaths reports (PFDs): A tool for patient safety in hospitals (7 September 2023)

   • Patient death
   • Investigation
   • (and 1 more)

     Tagged with:

     • Patient death
     • Investigation
     • Coroner reports

   By Patient-Safety-Learning, 18 September, 2023

   • 0 comments
   • 819 views
   • 
   • Added by Patient-Safety-Learning
   • 18 September, 2023

3. Prevention of Future Deaths report: Allison Aules (8 September 2023)

   • Self harm/ suicide
   • Children and Young People
   • (and 10 more)

     Tagged with:

     • Self harm/ suicide
     • Children and Young People
     • Patient death
     • Coroner reports
     • Coroner
     • Recommendations
     • Investigation
     • Adolescent
     • Mental health - CAMHS
     • Organisation / service factors
     • Funding
     • Lack of resources

   By Patient Safety Learning, 15 September, 2023

   • 0 comments
   • 1,422 views
   • 
   • Added by Patient Safety Learning
   • 15 September, 2023

4. Prevention of Future Deaths report: Ian Darwin (6 September 2023)

   • Investigation
   • Patient death
   • (and 5 more)

     Tagged with:

     • Investigation
     • Patient death
     • Coroner
     • Coroner reports
     • Patient safety incident
     • Reporting
     • Organisation / service factors

   By Patient Safety Learning, 12 September, 2023

   • 0 comments
   • 998 views
   • 
   • Added by Patient Safety Learning
   • 12 September, 2023

5. Prevention of Future Death report: Bethan Harris (22 June 2020)

   • Baby
   • Patient death
   • (and 6 more)

     Tagged with:

     • Baby
     • Patient death
     • Organisational learning
     • Midwife
     • Handover
     • Coroner
     • Coroner reports
     • Recommendations

   By Patient Safety Learning, 21 August, 2023

   • 0 comments
   • 898 views
   • 
   • Added by Patient Safety Learning
   • 21 August, 2023

6. Prevention of Future Deaths report: Heather Findlay (22 June 2023)

   • Patient death
   • Coroner reports
   • (and 7 more)

     Tagged with:

     • Patient death
     • Coroner reports
     • Coroner
     • Recommendations
     • Police
     • Self harm/ suicide
     • Collaboration
     • Organisation / service factors
     • Mental health

   By Patient Safety Learning, 26 July, 2023

   • 0 comments
   • 1,266 views
   • 
   • Added by Patient Safety Learning
   • 26 July, 2023

7. No More Deaths. Learning, action, and accountability: the case for a National Oversight Mechanism (Inquest, 27 June 2023)

   • Coroner reports
   • Coroner
   • (and 5 more)

     Tagged with:

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

   By Patient Safety Learning, 27 June, 2023

   • 0 comments
   • 1,137 views
   • 
   • Added by Patient Safety Learning
   • 27 June, 2023

8. Prevention of Future Deaths report: David Wilson (12 June 2023)

   • Coroner
   • Coroner reports
   • (and 1 more)

     Tagged with:

     • Coroner
     • Coroner reports
     • Consent

   By Mark Hughes, 22 June, 2023

   • 0 comments
   • 811 views
   • 
   • Added by Mark Hughes
   • 22 June, 2023

9. Prevention of Future Deaths report: Robert Stevenson (9 June 2023)

   • Medication
   • Self harm/ suicide
   • (and 3 more)

     Tagged with:

     • Medication
     • Self harm/ suicide
     • Patient death
     • Coroner
     • Coroner reports

   By Patient Safety Learning, 21 June, 2023

   • 0 comments
   • 885 views
   • 
   • Added by Patient Safety Learning
   • 21 June, 2023

10. Prevention of Future Deaths report: Sandra Finch (12 June 2023)

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

      Tagged with:

      • Patient death
      • Coroner reports
      • Coroner
      • Ambulance
      • Investigation
      • Care assessment
      • Diabetes
      • Emergency medicine

    By Patient Safety Learning, 14 June, 2023

    • 0 comments
    • 712 views
    • 
    • Added by Patient Safety Learning
    • 14 June, 2023

11. Learning from Preventable Deaths (submission to Health and Social Care Committee's Prevention Inquiry, Richards et al.)

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

      Tagged with:

      • Coroner reports
      • Patient death
      • Data
      • System safety

    By Patient_Safety_Learning, 30 May, 2023

    • 0 comments
    • 833 views
    • 
    • Added by Patient_Safety_Learning
    • 30 May, 2023

12. Preventable deaths involving medicines: a systematic case series of coroners’ reports 2013–22

    • Coroner reports
    • Medication
    • (and 1 more)

      Tagged with:

      • Coroner reports
      • Medication
      • Patient death

    By Patient_Safety_Learning, 17 May, 2023

    • 0 comments
    • 1,087 views
    • 
    • Added by Patient_Safety_Learning
    • 17 May, 2023

13. Averting a UK opioid crisis: getting the public health messages ‘right’ (30 March 2022)

    • Coroner reports
    • Medication
    • (and 1 more)

      Tagged with:

      • Coroner reports
      • Medication
      • Patient death

    By Patient_Safety_Learning, 12 May, 2023

    • 0 comments
    • 555 views
    • 
    • Added by Patient_Safety_Learning
    • 12 May, 2023

14. Lessons from web scraping coroners' Prevention of Future Deaths reports (January 2023)

    • Patient death
    • Data
    • (and 1 more)

      Tagged with:

      • Patient death
      • Data
      • Database

    By Patient_Safety_Learning, 11 May, 2023

    • 0 comments
    • 1,815 views
    • 
    • Added by Patient_Safety_Learning
    • 11 May, 2023

15. Preventing Future Deaths from Medicines: Responses to Coroners’ Concerns in England and Wales (8 October 2018)

    • Coroner reports
    • Medication
    • (and 1 more)

      Tagged with:

      • Coroner reports
      • Medication
      • Patient death

    By Patient_Safety_Learning, 10 May, 2023

    • 0 comments
    • 917 views
    • 
    • Added by Patient_Safety_Learning
    • 10 May, 2023

16. Prevention of future deaths report: Alexandra Briess (6 April 2023)

    • Allergies
    • Patient death
    • (and 6 more)

      Tagged with:

      • Allergies
      • Patient death
      • Surgery - ENT
      • Investigation
      • Coroner
      • Coroner reports
      • Recommendations
      • Anaesthesia

    By Patient Safety Learning, 19 April, 2023

    • 0 comments
    • 1,275 views
    • 
    • Added by Patient Safety Learning
    • 19 April, 2023

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

    • Coroner reports
    • Data

    By Patient_Safety_Learning, 23 March, 2023

    • 0 comments
    • 958 views
    • 
    • Added by Patient_Safety_Learning
    • 23 March, 2023

18. 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, 2023

    • 0 comments
    • 704 views
    • 
    • Added by Patient Safety Learning
    • 17 February, 2023

19. 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, 2023

    • 0 comments
    • 1,040 views
    • 
    • Added by Patient-Safety-Learning
    • 27 January, 2023

20. 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, 2023

    • 0 comments
    • 1,002 views
    • 
    • Added by Patient Safety Learning
    • 9 January, 2023

21. 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
    • 816 views
    • 
    • Added by Patient-Safety-Learning
    • 29 December, 2022

22. 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
    • 742 views
    • 
    • Added by Patient-Safety-Learning
    • 27 December, 2022

23. 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
    • 962 views
    • 
    • Added by Patient Safety Learning
    • 15 December, 2022

24. 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
    • 834 views
    • 
    • Added by Patient Safety Learning
    • 6 December, 2022

25. 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
    • 1,090 views
    • 
    • Added by Patient Safety Learning
    • 22 November, 2022