Coroner reports

Articles in this category

1. 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
   • 1,329 views
   • 
   • Added by Patient Safety Learning
   • 7 October, 2022

2. 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
   • 827 views
   • 
   • Added by Patient Safety Learning
   • 6 October, 2022

3. 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
   • 4,630 views
   • 
   • Added by Patient Safety Learning
   • 5 September, 2022

4. 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
   • 1,170 views
   • 
   • Added by Patient Safety Learning
   • 19 May, 2022

5. 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
   • 1,544 views
   • 
   • Added by Patient Safety Learning
   • 29 April, 2022

6. 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
   • 1,118 views
   • 
   • Added by Patient Safety Learning
   • 13 April, 2022

7. 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
   • 1,937 views
   • 
   • Added by Patient-Safety-Learning
   • 28 March, 2022

8. 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
   • 1,168 views
   • 
   • Added by Patient-Safety-Learning
   • 16 March, 2022

9. 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
   • 2,428 views
   • 
   • Comment by Patient-Safety-Learning
   • 15 March, 2022

10. 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
    • 1,881 views
    • 
    • Added by Mark Hughes
    • 14 March, 2022

11. 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
    • 4,833 views
    • 
    • Comment by Steve Turner
    • 15 March, 2022

12. 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
    • 1,225 views
    • 
    • Added by Patient-Safety-Learning
    • 7 March, 2022

13. 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
    • 1,399 views
    • 
    • Added by Patient-Safety-Learning
    • 1 March, 2022

14. 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
    • 1,733 views
    • 
    • Added by Patient Safety Learning
    • 25 February, 2022

15. 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
    • 1,769 views
    • 
    • Added by Patient Safety Learning
    • 17 February, 2022

16. 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
    • 1,356 views
    • 
    • Added by Patient-Safety-Learning
    • 15 February, 2022

17. Prevention of Future Deaths report - John Skinner (11 February 2022)

    • Coroner reports
    • Coroner
    • (and 4 more)

      Tagged with:

      • Coroner reports
      • Coroner
      • PPE (personal Protective Equipment)
      • Communication
      • Adminstering medication
      • Patient death

    By Patient Safety Learning, 15 February, 2022

    • 1 comment
    • 1,639 views
    • 
    • Comment by Flora Quin
    • 15 February, 2022

18. Prevention of Future Deaths report - Rebecca Romero (13 December 2017)

    • Mental health
    • Self harm/ suicide
    • (and 3 more)

      Tagged with:

      • Mental health
      • Self harm/ suicide
      • Mental health - CAMHS
      • Children and Young People
      • Patient death

    By Patient-Safety-Learning, 14 February, 2022

    • 0 comments
    • 1,012 views
    • 
    • Added by Patient-Safety-Learning
    • 14 February, 2022

19. The Coroners (Investigations) Regulations 2013: Part 7. Action to prevent other deaths

    • Coroner reports
    • Coroner
    • (and 3 more)

      Tagged with:

      • Coroner reports
      • Coroner
      • Investigation
      • Patient death
      • Regulatory issue

    By Patient Safety Learning, 3 February, 2022

    • 0 comments
    • 1,020 views
    • 
    • Added by Patient Safety Learning
    • 3 February, 2022

20. Guidance on Reports to Prevent Future Deaths (revised January 2016)

    • Coroner reports
    • Coroner
    • (and 3 more)

      Tagged with:

      • Coroner reports
      • Coroner
      • Patient death
      • Investigation
      • Regulatory issue

    By Patient Safety Learning, 3 February, 2022

    • 0 comments
    • 1,027 views
    • 
    • Added by Patient Safety Learning
    • 3 February, 2022

21. The role of the coroner: Presentation from Patricia Harding, Senior Coroner

    • Coroner
    • Coroner reports
    • (and 2 more)

      Tagged with:

      • Coroner
      • Coroner reports
      • Patient death
      • Investigation

    By Patient Safety Learning, 3 February, 2022

    • 0 comments
    • 1,597 views
    • 
    • Added by Patient Safety Learning
    • 3 February, 2022

22. Prevention of Future Deaths report – Barrie Housby (22 November 2021)

    • Patient death
    • Parkinsons disease
    • (and 4 more)

      Tagged with:

      • Patient death
      • Parkinsons disease
      • Safe staffing
      • Additional staff required
      • Falls
      • Coroner reports

    By Patient-Safety-Learning, 28 January, 2022

    • 0 comments
    • 1,585 views
    • 
    • Added by Patient-Safety-Learning
    • 28 January, 2022

23. Prevention of Future Deaths report – William Doleman, Anita Burkey, Peter Sellars and Carol Cole (23 December 2021)

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

      Tagged with:

      • Patient death
      • Coroner reports
      • Tests / investigations
      • Skill-based issue
      • Consent

    By Patient-Safety-Learning, 27 January, 2022

    • 0 comments
    • 1,147 views
    • 
    • Added by Patient-Safety-Learning
    • 27 January, 2022

24. Prevention of Future Deaths report – Mollie Dimmock (9 November 2021)

    • Patient death
    • Obstetrics and gynaecology/ Maternity
    • (and 3 more)

      Tagged with:

      • Patient death
      • Obstetrics and gynaecology/ Maternity
      • Baby
      • Maternity
      • Coroner reports

    By Patient-Safety-Learning, 24 January, 2022

    • 0 comments
    • 1,162 views
    • 
    • Added by Patient-Safety-Learning
    • 24 January, 2022

25. Prevention of Future Deaths report: Surekha Shivalkar (7 January 2022)

    • Coroner
    • Coroner reports
    • (and 8 more)

      Tagged with:

      • Coroner
      • Coroner reports
      • Patient death
      • Anaesthesia
      • Surgery - Trauma and orthopaedic
      • Communication
      • Risk assessment
      • Surgeon
      • Anaesthetist
      • Investigation

    By Patient Safety Learning, 18 January, 2022

    • 0 comments
    • 2,494 views
    • 
    • Added by Patient Safety Learning
    • 18 January, 2022