Recipient

Office of the Chief Coroner

First report 16 Dec 2013•Latest report 6 May 2026

Recipient record

Reports, concerns and published responses

Justice · Coronial office. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 75
Published responses: 1%
Concerns addressed: 2
Stated actions: 2

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

1%published responses found

2stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Office of the Chief Coroner linked to the concerns in each report. Select any concern, action or position to view the source wording.

14 Jun2016
Inner South London
Concerns raised1
1. Lack of non-hospital respite care options for mentally ill people in the community
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Christina O'Brien · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Christina O'Brien died by suicide on 17 September 2015 after hanging herself outside her flat; she also had injuries to her arms and legs. She had a long-term mental illness and was receiving treatment and care from SLAM. The principal concern was that community respite options for people experiencing mental health crises were limited, particularly after the withdrawal of Dove House, a non-hospital respite facility that had previously benefited her.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Lack of non-hospital respite care options for mentally ill people in the community
Wider context from the report
“(1) I am concerned that the options for mentally ill people in the community needing respite care through SLAM are limited solely to attendance by the Home Treatment team as the alternative to hospital admission. In this particular case I found that the availability of Dove House did, in the past, provide respite for the deceased. I also find, on the evidence I heard, that if this option had been available in 2015 the death might have been prevented. Whilst the Home Treatment team could provide support by way of medication and counselling it could not deal with the source of the distress the deceased was suffering from building work. (2) Given the unpredictability of the perceptions of people with mental illness in the community I also found that having a further option of respite residence in a non hospital setting could prevent future self-inflicted deaths. Examples that spring to mind, in a high density area like Lambeth, might be bullying by neighbours or sources of excessive noise from neighbouring residences as well as building work. (3) I am concerned the Dove House facility was withdrawn in about 2008 without any provision being made for alternative respite care when it appeared to have had a beneficial effect for the deceased and, by reasonable inference, other SLAM patients. ”
Open source report
11 May2016
South Wales Central
Concerns raised4
1. Increased risk of self-harm or suicide following adverse experiences of sectioning
2. Lack of continuity of treatment
3. Lack of an acute treatment facility for acute admission patients in Powys
1. Lack of an acute treatment facility for acutely unwell patients in Powys
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Gillian Rose Taylor · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Gillian Rose Taylor had a lengthy history of mental health issues and repeated suicide attempts. After being detained under the Mental Health Act and treated away from Powys because no acute bed was available locally, she remained under community mental health care until her death by hanging at home on 3 January 2016. The concerns included the lack of an acute treatment facility in Powys, resulting patient transfers, lack of continuity of treatment, and the possible adverse effect of this experience on her engagement with mental health professionals and risk of self-harm or suicide.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Increased risk of self-harm or suicide following adverse experiences of sectioning
Wider context from the report
“(3) The evidence showed that, on balance, it is likely that the experience of being sectioned in these circumstances had an adverse effect upon Mrs Taylor which fuelled an unwillingness, on her part, to engage with Mental Health professionals thereby increasing her risk of self harm/suicide. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Lack of continuity of treatment
Wider context from the report
“(2) As a consequence of 1 above there is often a lack of continuity of treatment which can be to the detriment of the patient concerned. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Lack of an acute treatment facility for acute admission patients in Powys
Wider context from the report
“(4) It is believed that Powys Health Board is the only Health Board in the country that has no facility available to it for the treatment of acute admission patients in the position of Mrs Taylor. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Lack of an acute treatment facility for acutely unwell patients in Powys
Wider context from the report
“(1) There is no acute facility in Powys for the treatment of acutely unwell patients, which the evidence showed, often leads to patients being moved the length and breadth of the country to an establishment where a bed can be found. The evidence also showed that the local acute unit at the Redwoord Centre in Shrewsbury had recently experienced a significant reduction in the number of acute beds available compounding and exacerbating the problem. ”
Open source report
20 Apr2016
South Wales Central
Concerns raised4
1. Failure to provide timely ambulance responses to Amber 2 calls
2. Failure to make timely follow-up calls to update, advise and reassess emergency callers
3. Lack of clear planning and direction for maintaining and delivering ambulance services
1. Failure to maintain ambulance service delivery during significant call volumes
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Ronald Hamer · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Ronald Hamer, an elderly man living independently at home, fell in his bathroom on 8 February 2016 and remained immobilised on the floor for over 13½ hours before being found. He was taken to hospital after a delayed ambulance response and died there on the morning of 10 February 2016. Concerns included the ambulance response time, the lack of timely follow-up contact with the family, and inadequate planning and direction during periods of very high call volumes.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide timely ambulance responses to Amber 2 calls
Wider context from the report
“1) As against an internal Welsh Ambulance Services Trust response target time for an Amber 2 call of 20 minutes, an ambulance did not arrive at the scene for nearly 2 hours and 40 minutes. It was accepted in evidence on behalf of the Welsh Ambulance Services Trust that this response time was unacceptable and that the situation could happen again. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Failure to make timely follow-up calls to update, advise and reassess emergency callers
Wider context from the report
“2) Cognisant of the delay in responding to the original call to the emergency services, good practice of the Welsh Ambulance Services Trust would have been to have made a phone call(s) to seek an update on the condition of the patient, to provide further advice and to ascertain whether it would have been appropriate to re-categorise the call. A call was not made to the family of the deceased (and this was disputed in evidence in any event) until just before 8:25pm, 1½ hours after the original call had been made. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Lack of clear planning and direction for maintaining and delivering ambulance services
Wider context from the report
“3) The evidence suggested that at or around the time of the first call being made to the Welsh Ambulance Services Trust at around 6:50pm on the 8th February 2016 there was an extremely high number of calls being polled. The evidence suggested that there was an absence of clear planning and direction as to the maintenance and delivery of the Trust's services and that in repeat circumstances of such significant polling the same circumstances as found at the inquest of Mr Hamer could repeat themselves. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain ambulance service delivery during significant call volumes
Wider context from the report
“3) The evidence suggested that at or around the time of the first call being made to the Welsh Ambulance Services Trust at around 6:50pm on the 8th February 2016 there was an extremely high number of calls being polled. The evidence suggested that there was an absence of clear planning and direction as to the maintenance and delivery of the Trust's services and that in repeat circumstances of such significant polling the same circumstances as found at the inquest of Mr Hamer could repeat themselves. ”
Open source report
19 Apr2016
South Wales Central
Concerns raised1
1. Lack of an advance warning sign for the approaching left bend
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Rhodri Dafydd Miller-Binding and 3 others · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

On 6 March 2015, a vehicle collision on the A470 near the Storey Arms, Brecon resulted in the deaths of Rhodri Dafydd Miller-Binding, Corey Bailey Price, Alesha Marie O’Connor and Margaret Elizabeth Challis. The principal concern was that the challenging bend lacked an advance warning sign, which the inquest evidence indicated could help reduce the risk of similar fatal collisions.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Lack of an advance warning sign for the approaching left bend
Wider context from the report
“1) The stretch of road along the A470 is subject to a 60 mile per hour speed limit but is known to be particularly “challenging” stretch of road on which there have been many serious injury and fatality collisions in the past. The evidence at the inquest from the Forensic Collision Investigating Officer was clear in that an advanced warning sign of an approaching left bend would be of significant assistance in warning motorists of the nature of the road ahead and thereby reducing the risk of a similar fatality. Whilst there was evidence at the inquest to support the view that Rhodri Milling- Binding’s vehicle was being driven at an inappropriate speed, it was not felt that any form of speed restriction was appropriate at this location – simply an advanced warning sign of the nature of the road ahead. ”
Open source report
12 Nov2015
Powys, Bridgend and Glamorgan Valleys
Concerns raised1
1. Delays in ambulance attendance
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Christopher George Connor · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Christopher George Connor had been socialising at a public house before leaving in the early hours and being found collapsed and unresponsive on a pavement near his home. An ambulance took over 1 hour and 15 minutes to arrive, and the principal concern was the delay in ambulance attendance.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Delays in ambulance attendance
Wider context from the report
“(1) The delay in the attendance of an ambulance which, on the evidence, only arrived after police officers arrived on the scene and “expedited” the call to the ambulance control room. ”
Open source report
4 Sep2015
Powys, Bridgend and Glamorgan Valleys
Concerns raised4
1. Inadequate monitoring of INR levels
2. Inadequate communication about anticoagulation monitoring and potential therapy adjustment
3. Lack of certainty whether Warfarin was being taken
1. Failure to admit a patient to hospital when a possible ischaemic leg requires assessment and anticoagulation adjustment
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Mrs. Mary Patricia James · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mrs. Mary Patricia James had a prosthetic heart valve requiring anticoagulation, but INR monitoring was inadequate and there was uncertainty about whether she was taking Warfarin. Concerns included failures in communication between the INR Unit, care home and GP, and that she was not admitted to hospital on 15 May 2015 despite concern about a possible ischaemic leg. The inquest concluded: “Ischaemic leg contributed to by inadequate Warfarin monitoring and dosing”.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Inadequate monitoring of INR levels
Wider context from the report
“(1) Inadequate monitoring of INR levels in a patient suffering from dementia; ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Inadequate communication about anticoagulation monitoring and potential therapy adjustment
Wider context from the report
“(3) Inadequate communication between the INR Unit, the Care Home and the GP regarding this patient’s anticoagulation monitoring and the potential need for therapy adjustment; ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Lack of certainty whether Warfarin was being taken
Wider context from the report
“(2) Lack of certainty whether Warfarin was being taken by the patient; ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Failure to admit a patient to hospital when a possible ischaemic leg requires assessment and anticoagulation adjustment
Wider context from the report
“(4) That against this background and the Care Home’s concern about a possible ischaemic leg, Mrs. James was not admitted to hospital on the 15th May, 2015 when there may have been a window of opportunity to have adjusted the anticoagulation therapy. ”
Open source report
27 Jul2015
Powys, Bridgend and Glamorgan Valleys
Concerns raised4
1. Insufficient staffing of Tissue Viability Nurses
2. Failure to maintain adequate repositioning charts
3. Failure to maintain adequate pressure ulcer documentation
1. Lack of integrated skin care across Health Boards and Primary healthcare services
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Mr. Arthur Cook · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mr. Arthur Cook had poor circulation and a chronic open wound that developed into an MRSA-infected category 4 pressure ulcer while he was resident at Four Seasons Healthcare Residential Home. He failed to respond to treatment and died. Concerns included insufficient tissue viability nursing capacity, inadequate pressure-ulcer documentation and repositioning charts, and a lack of integrated skin care across services.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Insufficient staffing of Tissue Viability Nurses
Wider context from the report
“(1) Staffing levels of Tissue Viability Nurses within the Aneurin Bevan Health Board are low and to the extent that at times this service cannot be provided according to need; ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain adequate repositioning charts
Wider context from the report
“(2) The CTUHB and residential Care Home failed to maintain adequately pressure ulcer documentation and repositioning charts making more likely the progression of MRSA infected pressure ulcers and wounds failing to heal. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain adequate pressure ulcer documentation
Wider context from the report
“(2) The CTUHB and residential Care Home failed to maintain adequately pressure ulcer documentation and repositioning charts making more likely the progression of MRSA infected pressure ulcers and wounds failing to heal. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Lack of integrated skin care across Health Boards and Primary healthcare services
Wider context from the report
“(3) An apparent lack of integrated skin care within and between Health Boards and Primary healthcare services. ”
Open source report
24 Apr2015
Powys, Bridgend and Glamorgan Valleys
Concerns raised2
1. Unreliable booking system for community INR testing
2. Unreliable notification system for omissions by family or carers
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Mrs. Hilda May Harris · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mrs. Hilda May Harris, aged 86, suffered a cerebral infarction with an intracerebral haemorrhage on 04.01.15 after an additional INR test was not undertaken while she was taking Warfarin alongside medication for gout. The report identified unreliable systems for booking community INR tests and for notifying or acting on omissions.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Unreliable booking system for community INR testing
Wider context from the report
“(1) The current booking system for community INR testing is unreliable with scope for appointments not being transferred from one set of papers to another. (2) Where an omission occurs, the notification system (by the family or carers) also appears unreliable. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Unreliable notification system for omissions by family or carers
Wider context from the report
“(1) The current booking system for community INR testing is unreliable with scope for appointments not being transferred from one set of papers to another. (2) Where an omission occurs, the notification system (by the family or carers) also appears unreliable. ”
Open source report
19 Mar2015
Cardiff and Vale of Glamorgan
Concerns raised3
1. Insufficient staffing capacity for safe patient oversight
2. Failure to maintain complete and consistent nursing and clinical records
3. Failure to undertake nursing observations in accordance with required procedures and guidance
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Elsie May Hayward · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Elsie May Hayward was admitted to hospital after a fall at home and was being treated for sepsis. During her admission, she sustained four falls, including a likely fall from her bed that caused a head injury and subdural haematoma; her condition deteriorated and she died three days later. Concerns included overstretched staffing, inadequate post-head-injury observations, and omissions and inconsistencies in clinical records and communication.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Insufficient staffing capacity for safe patient oversight
Wider context from the report
“1. On the 7th January 2015 medical staff were having to care for 50% more patients over what is generally considered to be safe staffed patient ratio. The evidence showed that the team was significantly overstretched and as a result were not able to oversee the care to this lady. Because of the pressures on the team it is likely that there were deficiencies in the care afforded to her which may have contributed to her repeated falls. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain complete and consistent nursing and clinical records
Wider context from the report
“3. There were extensive omissions in the note taking and a clear inconsistency between the “nursing notes” and “clinical notes” resulting in confusion and breakdown of communication between the nursing staff and the medical team. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Failure to undertake nursing observations in accordance with required procedures and guidance
Wider context from the report
“2. Despite clear guidance and directive the nursing observations on the deceased following her head injury were not undertaken in accordance with the Health Boards procedure and the N.I.C.E. national guidance. ”
Open source report
18 Mar2015
Leicester City and South Leicestershire
Concerns raised2
1. Inadequate visibility at the road traffic junction
2. Absence or inadequacy of filter lanes at the road traffic junction
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Anais Chantal Thouvenot · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Anais Chantal Thouvenot was knocked from her bicycle by a passing vehicle at a road junction in Leicester on 9 November 2014, sustained a serious head injury, and died at Queens Medical Centre, Nottingham, on 16 November 2014. Concerns were raised about the junction’s safety, including visibility, inadequate or absent filter lanes, heavy traffic, and the road contour, with reported near misses involving cyclists.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Inadequate visibility at the road traffic junction
Wider context from the report
“During the course of the investigation I was made aware of specific concerns regarding the safety of the road traffic junction at Upper Kings Street and Regent Road, Leicester. These concerns were highlighted to me by the Leicester Cycling Campaign Group (LCCG) and a member of the public ████████ who has also raised these concerns for the attention of Councillors ████████ and ████████. The LCCG have informed me that they believe the junction to be inherently dangerous quoting a number of 'near misses' as experienced by their cycling group. The specific concerns relate to visibility at the junction and absent or inadequate filter lanes, exacerbated by heavy traffic and the contour of the road at this junction. It is also known to be on a major cycle route into the city. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Absence or inadequacy of filter lanes at the road traffic junction
Wider context from the report
“During the course of the investigation I was made aware of specific concerns regarding the safety of the road traffic junction at Upper Kings Street and Regent Road, Leicester. These concerns were highlighted to me by the Leicester Cycling Campaign Group (LCCG) and a member of the public ████████ who has also raised these concerns for the attention of Councillors ████████ and ████████. The LCCG have informed me that they believe the junction to be inherently dangerous quoting a number of 'near misses' as experienced by their cycling group. The specific concerns relate to visibility at the junction and absent or inadequate filter lanes, exacerbated by heavy traffic and the contour of the road at this junction. It is also known to be on a major cycle route into the city. ”
Open source report
4 Mar2015
Powys, Bridgend & Glamorgan Valleys
Concerns raised2
1. Failure of paper records to accurately document Consultant patient review
2. Unavailability of Community medical records at hospital admission
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Mr. Brian Francis · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mr. Brian Francis was admitted to Princess of Wales Hospital on 5 September 2014 after several days of illness and was treated for presumed chest sepsis. He died of a pulmonary embolism the following day. Concerns included a failed process for recording Consultant attendance and the unavailability of Community medical records, which may have affected assessment and the commencement of anti-coagulation therapy.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Failure of paper records to accurately document Consultant patient review
Wider context from the report
“(1) The process of a Consultant’s attendance on patient being noted by a ‘tick in the box’ on a paper record failed. The box had been ticked when in fact the patient had not been reviewed by the Consultant. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Unavailability of Community medical records at hospital admission
Wider context from the report
“(2) Had the Community medical records been available at the time of hospital admission the patient would most probably have been assessed differently and in all probability, anti-coagulation therapy commenced immediately or shortly thereafter. ”
Open source report
19 Feb2015
Powys, Bridgend and Glamorgan Valleys
Concerns raised4
1. Failure to ensure crisis team responsibility for providing assistance
2. Failure to make clinical records of crisis team contact
3. Failure to undertake risk assessments specific to suicidal ideation
1. Lack of a formal communication mechanism between mental health out-patient and acute services
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Barrie Lewis · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Barrie Lewis was found by his family hanging from a rope attached to a garage rafter on 31 August 2014. The inquest concluded that his death was suicide. Concerns included the absence of a specific risk assessment for suicidal ideation, poor communication between mental health services, no reliable system assigning responsibility for assistance, and a lack of clinical records of crisis-team contact.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure crisis team responsibility for providing assistance
Wider context from the report
“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) A clinical review was undertaken of the contact the deceased had with the mental health services in the days prior to his death and it was apparent from that review, and from the evidence heard that: a) That no risk assessment was undertaken to detail risks specifically associated with the deceased’s suicidal ideation which, on the evidence, would have assisted the crisis team in assessing his risk of suicide or self harm. b) There was little formal mechanism for communication between the mental health out patients department and the acute services which he accessed in the days prior to his death. c) There was no reliable system to ensure that a member of the crisis team took responsibility for providing assistance to the deceased – simply leaving the deceased to make his own telephone call to the appropriate department. d) No clinical recordings were made of the contact the deceased had with the crisis team (Crisis Resolution Home Treatment team) following his contact with them. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Failure to make clinical records of crisis team contact
Wider context from the report
“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) A clinical review was undertaken of the contact the deceased had with the mental health services in the days prior to his death and it was apparent from that review, and from the evidence heard that: a) That no risk assessment was undertaken to detail risks specifically associated with the deceased’s suicidal ideation which, on the evidence, would have assisted the crisis team in assessing his risk of suicide or self harm. b) There was little formal mechanism for communication between the mental health out patients department and the acute services which he accessed in the days prior to his death. c) There was no reliable system to ensure that a member of the crisis team took responsibility for providing assistance to the deceased – simply leaving the deceased to make his own telephone call to the appropriate department. d) No clinical recordings were made of the contact the deceased had with the crisis team (Crisis Resolution Home Treatment team) following his contact with them. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Failure to undertake risk assessments specific to suicidal ideation
Wider context from the report
“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) A clinical review was undertaken of the contact the deceased had with the mental health services in the days prior to his death and it was apparent from that review, and from the evidence heard that: a) That no risk assessment was undertaken to detail risks specifically associated with the deceased’s suicidal ideation which, on the evidence, would have assisted the crisis team in assessing his risk of suicide or self harm. b) There was little formal mechanism for communication between the mental health out patients department and the acute services which he accessed in the days prior to his death. c) There was no reliable system to ensure that a member of the crisis team took responsibility for providing assistance to the deceased – simply leaving the deceased to make his own telephone call to the appropriate department. d) No clinical recordings were made of the contact the deceased had with the crisis team (Crisis Resolution Home Treatment team) following his contact with them. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Lack of a formal communication mechanism between mental health out-patient and acute services
Wider context from the report
“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) A clinical review was undertaken of the contact the deceased had with the mental health services in the days prior to his death and it was apparent from that review, and from the evidence heard that: a) That no risk assessment was undertaken to detail risks specifically associated with the deceased’s suicidal ideation which, on the evidence, would have assisted the crisis team in assessing his risk of suicide or self harm. b) There was little formal mechanism for communication between the mental health out patients department and the acute services which he accessed in the days prior to his death. c) There was no reliable system to ensure that a member of the crisis team took responsibility for providing assistance to the deceased – simply leaving the deceased to make his own telephone call to the appropriate department. d) No clinical recordings were made of the contact the deceased had with the crisis team (Crisis Resolution Home Treatment team) following his contact with them. ”
Open source report
21 Jan2015
West Yorkshire (Western)
Concerns raised3
1. Failure to obtain appropriate senior medical review or support when deterioration is identified
2. Failure to make accurate and complete doctors’ records
3. Failure to make complete and accurate nursing records
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Phillip Roy Smith · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Phillip Roy Smith was diagnosed with a likely pancreatic carcinoma and underwent a percutaneous transhepatic cholangiogram with external drain insertion. He deteriorated overnight with severe pain, vomiting and a subsequent cardiac arrest, and died in intensive care on 15 March 2014 after treatment was withdrawn. The concerns included missing nursing and doctors’ records, undocumented observations, medication, blood gas results and fall details, and the junior doctor’s decision not to seek additional senior support despite concerns about Mr. Smith’s deterioration.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Failure to obtain appropriate senior medical review or support when deterioration is identified
Wider context from the report
“(3) Junior Doctor’s Involvement i) The senior nurse on duty was concerned of Mr. Smith’s deterioration in the early hours of the 15th March. At the time of the junior doctor’s attendance she suggested that a more senior medical review should take place, however the junior doctor indicated that he did not require any further support in the circumstances notwithstanding Mr. Smith’s presentation. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Failure to make accurate and complete doctors’ records
Wider context from the report
“(2) Standard of Doctors’ Records i) Junior Doctor’s involvement – neither the junior or middle grade doctors who reviewed Mr. Smith in the early hours of the 15th March 2014 made accurate records of their review and assessment of Mr. Smith. ii) Blood gasses assessment was undertaken by the junior doctor on his attendance around 1.30 a.m. but no record was made of this. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Failure to make complete and accurate nursing records
Wider context from the report
“(1) The Standard of Nursing Records i) On the evening of the 14th March 2014 observation were repeated 30 minutes after the standard observations were undertaken, but no record was made of these repeat observations. ii) Mr. Smith declined his evening medications, but this was not recorded. iii) Mr. Smith was given Tramadol at around 1.00 a.m. on the morning of the 15th March but this was not recorded. iv) Mr. Smith was found laid on the floor beside his bed in the early hours of the 15th March but full details of this event was not made by the nursing staff on duty. ”
Open source report
19 Dec2014
Powys, Bridgend and Glamorgan Valleys
Concerns raised3
1. Delays in Tissue Viability Nurse and wound care input
2. Insufficient Tissue Viability Nurse capacity to serve the regional hospitals
3. Specialist nurses not being based in the hospital for TVN and wound care input
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Mr. Thomas Jenkins · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mr. Thomas Jenkins developed pressure sores while receiving care after a cerebrovascular accident, including an infected chronic pressure sore on his right heel. He was readmitted to hospital and died of sepsis on 8 August 2014. The principal concern was inadequate and delayed tissue viability nursing and wound care input, attributed to specialist nurses not being based in the hospital and insufficient staffing across the region.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Delays in Tissue Viability Nurse and wound care input
Wider context from the report
“(1) Tissue Viability Nurse (TVN) input was requested at different times during the 7 month period whilst Mr. Jenkins was being nursed in YCR yet response was slow (as long as a week after a ward visit was requested). In fact the TVN did not assess the ulcer until 06.06.14 almost 2 months after its development and by which time the odour from the wound was described as ‘very offensive’. A bandage used was reported as the likely cause of a new ulcer forming - Datrix incident report 14.07.14. (2) The key concern is that of inadequate TVN and wound care input. The inadequate care in this instance was attributed to specialist nurses not being based in the hospital and of insufficient TVNs to serve the several hospitals in the region. The service being overstretched. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Insufficient Tissue Viability Nurse capacity to serve the regional hospitals
Wider context from the report
“(1) Tissue Viability Nurse (TVN) input was requested at different times during the 7 month period whilst Mr. Jenkins was being nursed in YCR yet response was slow (as long as a week after a ward visit was requested). In fact the TVN did not assess the ulcer until 06.06.14 almost 2 months after its development and by which time the odour from the wound was described as ‘very offensive’. A bandage used was reported as the likely cause of a new ulcer forming - Datrix incident report 14.07.14. (2) The key concern is that of inadequate TVN and wound care input. The inadequate care in this instance was attributed to specialist nurses not being based in the hospital and of insufficient TVNs to serve the several hospitals in the region. The service being overstretched. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Specialist nurses not being based in the hospital for TVN and wound care input
Wider context from the report
“(1) Tissue Viability Nurse (TVN) input was requested at different times during the 7 month period whilst Mr. Jenkins was being nursed in YCR yet response was slow (as long as a week after a ward visit was requested). In fact the TVN did not assess the ulcer until 06.06.14 almost 2 months after its development and by which time the odour from the wound was described as ‘very offensive’. A bandage used was reported as the likely cause of a new ulcer forming - Datrix incident report 14.07.14. (2) The key concern is that of inadequate TVN and wound care input. The inadequate care in this instance was attributed to specialist nurses not being based in the hospital and of insufficient TVNs to serve the several hospitals in the region. The service being overstretched. ”
Open source report
18 Dec2014
Powys, Bridgend and Glamorgan Valleys
Concerns raised3
1. Unusually high number of collisions at a particular road location
2. Excessive vehicle speeds at or near the collision location
3. Excessive vehicle speeds on bends at the road location
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Brendan Owain Ryan · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Brendan Owain Ryan, aged 21, was the front-seat passenger in a Peugeot 205 that left the A488 between Pen-Y-Bont and Knighton on 31 July 2013 and collided with a fence before entering a field. He was declared deceased at the scene; the inquest concluded the death was due to a road traffic collision, with neck injuries recorded as the medical cause. The principal concern was an unusually high number of collisions at or near the location, with evidence indicating that excessive speed was likely, and consideration of a restricted speed area was raised.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Unusually high number of collisions at a particular road location
Wider context from the report
“1. There is evidence of an unusually high number of incidents taking place at this particular location. Powys County Council are aware of three injury collisions and there is evidence, from the residents of Brook House, that there have been many accidents at or near this location which the evidence indicated are most likely to have been caused by excess speed. Furthermore it is believed there were three collisions at or near this collision site within a six day period surrounding this incident. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Excessive vehicle speeds at or near the collision location
Wider context from the report
“1. There is evidence of an unusually high number of incidents taking place at this particular location. Powys County Council are aware of three injury collisions and there is evidence, from the residents of Brook House, that there have been many accidents at or near this location which the evidence indicated are most likely to have been caused by excess speed. Furthermore it is believed there were three collisions at or near this collision site within a six day period surrounding this incident. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Excessive vehicle speeds on bends at the road location
Wider context from the report
“2. Evidence from the Collision Investigator in this case showed that the maximum speed at which the bends in this road at this location could be travelled at were 50 and 53 mph depending on the direction of approach. Whilst it is acknowledged that the County Council have installed new signage and double white lines in the area in light of the unusually high number of incidents in which vehicles appear to have left the road, most likely as a direct result of excessive speed, it is felt that consideration ought to be given to a restricted speed area at this location. ”
Open source report
14 Nov2014
Powys, Bridgend and Glamorgan Valleys
Concerns raised2
1. Recurring collisions on the road
2. Busy road requiring drivers to cross oncoming traffic during rush hour
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Mr. Marcus Szigetvari · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mr. Marcus Szigetvari was fatally injured when his motorcycle collided with a Vauxhall Vectra at a junction on the A4233 Ynysrhy bypass in darkness and poor, rainy weather. Concerns included the difficulty for drivers exiting Llanwanno Road to cross oncoming traffic, possible misjudgement of the motorcycle’s single headlight, and nineteen other reported collisions on the road since 2001, including two fatalities.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Recurring collisions on the road
Wider context from the report
“(2) ████████ Investigation Officer, reported nineteen other collisions on this road since 2001, two of which were fatalities. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Busy road requiring drivers to cross oncoming traffic during rush hour
Wider context from the report
“(1) The road is busy especially during the ‘rush hour’ period resulting it drivers exiting the Llannwanno Road having to ‘seize the moment’ to cross oncoming traffic to enter the lane towards Aberdare. The evidence suggested that the most likely cause of the deceased losing his life was that the driver of the car mistook his motorcycle’s single headlight for that of a car travelling behind him at a further distance. This was reported at the inquest to have been an easy misjudgement in dark and poor weather conditions. ”
Open source report
29 Oct2014
Powys, Bridgend and Glamorgan Valleys
Concerns raised2
1. Protruding road studs creating a motorcycle loss-of-control hazard
2. Inadequate road markings permitting overtaking on a road with a side entrance and obscured visibility
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Alan Derek Evans · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Alan Derek Evans died at the scene after losing control of his motorcycle while overtaking on the A489, colliding with an oncoming vehicle and being run over by another vehicle. Concerns included the road’s single broken white line and whether a protruding old-style cat’s eye may have contributed to the loss of control.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Protruding road studs creating a motorcycle loss-of-control hazard
Wider context from the report
“(2) The evidence suggested that one of the most likely causes of the deceased losing control of his motorcycle was contact with a protruding cats eye. This was agreed by the senior investigation officer and the collision investigation officer who both held the view that this may have contributed to the accident. Consideration in my view ought to be given to replacing the “old style cats eyes” with the newer “slim line” version to minimise this risk in the future should it not be considered appropriate to make the area subject to double white lines to prohibit overtaking. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Inadequate road markings permitting overtaking on a road with a side entrance and obscured visibility
Wider context from the report
“(1) The road at this particular location is governed by a single broken white line indicating that overtaking is permitted. Given the layout of the road, the existence of a side entrance to it, the impact of hedges obscuring the view of the road consideration, in my opinion, ought to be given to putting double white line markings on this particular stretch of road. ”
Open source report
17 Oct2014
West Yorkshire Eastern
Concerns raised5
1. Delays in summoning emergency medical services
2. Failure to record relevant inmate behaviour and presentation information in the Wing Observation Book
3. Incomplete Wing staff training in the use of breathalyser equipment
1. Failure to use emergency codes when required
2. Inadequate vigilance over inmate social gatherings during periods of association
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

William Thomas Anderson · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

William Thomas Anderson died in his cell at HMP Wealstun on 19 September 2010 after taking prescription medication belonging to others and drinking hooch, having appeared intoxicated or under the influence of alcohol or drugs the previous afternoon. The concerns included insufficient vigilance around inmate gatherings involving drugs and alcohol, incomplete staff training and recording of observations, failure to use an emergency code, and delay in summoning paramedic assistance.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Delays in summoning emergency medical services
Wider context from the report
“(5) Paramedic assistance was not called within a reasonable time and no explanation for the delay was provided in the course of the Inquest. Whilst the failure to summons outside medical assistance sooner would not have affected the outcome in this instance, it is not inconceivable that to omit to call for such assistance as soon as possible could, in certain circumstances, jeopardise an inmate’s chances of survival. Consequently, emergency services should be summoned at the very first available opportunity, and all Prison staff should be instructed as to the importance of so doing. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Failure to record relevant inmate behaviour and presentation information in the Wing Observation Book
Wider context from the report
“(3) The Deceased’s behaviour and presentation on the 18th September 2010 was not recorded by any member of Wing staff in the C Wing Observation Book. Evidence was adduced in the course of the Inquest as to the importance of recording all relevant information in the said Observation Book, thereby apprising all members of Wing staff on all shifts of all material facts and matters. In the circumstances, all relevant information in relation to, for example, an inmate’s behaviour and general presentation should be brought to the attention of all Wing staff and should be done so via an appropriate entry/entries in the Wing Observation Book. All Wing staff (Wing Managers, Prison Officers and Operational Support Grades) should be made aware of the importance of such, and should ensure information is recorded accordingly; ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Incomplete Wing staff training in the use of breathalyser equipment
Wider context from the report
“(2) The Deceased was not subjected to a breathalyser test at any time during the 18th September 2010. A proportion of, but not all, Wing staff are trained in the use of such breathalyser equipment. Had the Deceased been so breathalysed, more likely than not, it would have been apparent he was not suffering from the effects of alcohol. In the circumstances all Wing staff should be trained in the use of such breathalyser equipment; ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Failure to use emergency codes when required
Wider context from the report
“(4) The members of staff who observed the Deceased at around 5.45am on the 19th September 2010 did not “put out” a Code Blue. It was explained in the course of the Inquest that Codes Blue and Red are basic emergency codes which have been in existence for very many years. Despite the fact that, in this instance, the failure to call a Code Blue would not have affected the outcome, it is not inconceivable that to omit to use such emergency codes could, in certain circumstances, jeopardise an inmate’s chances of survival. In the circumstances, all Prison staff should be fully acquainted with the use of such codes and should use them accordingly; ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Inadequate vigilance over inmate social gatherings during periods of association
Wider context from the report
“(1) Evidence was adduced in the course of this Inquest to the effect that in 2010, 2011 and 2012 inmates were having social get togethers on C Wing at HMP Wealstun, in particular at a weekend, during which time drugs were taken and hooch was drunk. Evidence was also heard that this is occurring at the present time at this said prison establishment. In the circumstances, there should be much greater and effective vigilance by Wing staff and Prison Service employees at HMP Wealstun in relation to such get togethers on the Wings during periods of association; ”
Open source report
9 Jun2014
Teesside
Concerns raised1
1. Hazardous forceful and sudden movement of a back door caused by airflow between open doors
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Charles Ronald Hardiman · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

On 26 February 2014, Charles Ronald Hardiman was pushed backwards by a back door moved suddenly by a gust of wind while he was at the top of steps at a public house. He fell down the stairs and sustained fatal head and chest injuries. The principal concern was that open front and back doors created a wind tunnel, causing the back door to move forcibly and suddenly.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Hazardous forceful and sudden movement of a back door caused by airflow between open doors
Wider context from the report
“(1) It was reported that the front door to the Public House was open and created a wind tunnel when the back door was open. This forced the back door to move forcibly and suddenly resulting in the accident. ”
Open source report
19 May2014
Powys, Bridgend and Glamorgan Valleys
Concerns raised3
1. Insufficient illumination affecting driver visibility on the south bound carriageway
2. Obscuration of street lamp 18 by overhanging foliage
3. Failure of street lamp 19 to provide illumination
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Stephen John Owens · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Stephen John Owens was fatally injured in a running-down accident on the Ely Valley Road on 29 August 2013. Concerns related to an unilluminated street lamp, another lamp obscured by foliage, and the resulting level of illumination possibly affecting the driver's ability to see him.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Insufficient illumination affecting driver visibility on the south bound carriageway
Wider context from the report
“(1) Street lamp number 19 situated on the pavement to the north bound carriageway of the Ely Valley Road was unilluminated at the time of the collision. (2) Street lamp number 18 again on the pavement adjacent to the north bound carriageway of the Ely Valley Road was obscured by overhanging foliage. (3) Consequent upon (1) and (2) the level of illumination in the proximity of the collision was likely to have had an effect upon the ability of the driver to see the deceased ahead of him on the south bound carriageway. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Obscuration of street lamp 18 by overhanging foliage
Wider context from the report
“(1) Street lamp number 19 situated on the pavement to the north bound carriageway of the Ely Valley Road was unilluminated at the time of the collision. (2) Street lamp number 18 again on the pavement adjacent to the north bound carriageway of the Ely Valley Road was obscured by overhanging foliage. (3) Consequent upon (1) and (2) the level of illumination in the proximity of the collision was likely to have had an effect upon the ability of the driver to see the deceased ahead of him on the south bound carriageway. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Failure of street lamp 19 to provide illumination
Wider context from the report
“(1) Street lamp number 19 situated on the pavement to the north bound carriageway of the Ely Valley Road was unilluminated at the time of the collision. (2) Street lamp number 18 again on the pavement adjacent to the north bound carriageway of the Ely Valley Road was obscured by overhanging foliage. (3) Consequent upon (1) and (2) the level of illumination in the proximity of the collision was likely to have had an effect upon the ability of the driver to see the deceased ahead of him on the south bound carriageway. ”
Open source report
13 Jan2014
East Sussex
Concerns raised4
1. Lack of a SLOW carriageway marking on the approach to the bend
2. Failure of chevron signs to have yellow backgrounds
3. Collision black spot at the bend
1. Potential carriageway hazard from a maturing eucalyptus sapling
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Mustafa Cicek · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mustafa Cicek died following a road traffic collision on the A21 when his Ford Fiesta left the carriageway on a bend and struck a fixed structure. The concerns identified included the bend being a collision black spot, inadequate chevron-sign visibility, a potentially hazardous sapling, and the need for a “SLOW” road marking.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Lack of a SLOW carriageway marking on the approach to the bend
Wider context from the report
“(4) Consideration should be given to painting “SLOW” in the carriageway on the approach to the bend. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Failure of chevron signs to have yellow backgrounds
Wider context from the report
“(2) The apparatus along the carriageway, particularly two of the chevron signs, could be improved. There are three chevron signs but only one has a yellow background. If the two chevron signs without a yellow background could have a yellow background added it would further enhance their presence on this bend. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Collision black spot at the bend
Wider context from the report
“(1) The bend at this particular location is a collision black spot as there have been several road traffic collisions at the location of Mr Cicek’s collision. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Potential carriageway hazard from a maturing eucalyptus sapling
Wider context from the report
“(3) A Eucalyptus sapling has been planted on Highways Agency land between the front fence at ████████ and the edge of the carriageway. This will mature into a potential hazard and consideration should be given to its removal. ”
Open source report
16 Dec2013
Nottinghamshire
Concerns raised5
1. Delays in consultation and responses to telephone referrals
2. Inability of reception staff to interrupt GPs to alert and inform them of changes in a patient’s condition following telephone referrals
3. Failure to fully and properly document discussions with patients or their families
1. Failure to determine an adequate threshold for telephone versus home consultation
2. Failure to fully assess patients’ mental capacity when they refuse medical treatment or hospital admission
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Cynthia Fretwell · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Cynthia Fretwell, aged 84, was admitted to hospital with abdominal pain, obstructive jaundice and suspected gallbladder inflammation, but was discharged after treatment with antibiotics. She later became unwell at home, was not admitted to hospital after GP contacts including a telephone consultation, and died that evening from peritonitis resulting from an infected gall bladder that had not responded to antibiotics. Concerns included telephone referral systems and responses, the threshold for telephone versus home consultations, assessment of mental capacity when refusing treatment or admission, and documentation of discussions.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Delays in consultation and responses to telephone referrals
Wider context from the report
“(1) Telephone referrals and the lack of an effective system for conveying and responding to information between the caller and the doctor. Specifically, I had concerns about the following aspects: (a) The inability of reception staff to interrupt a GP during surgery for the purposes of alerting and informing the doctor of a change in the patient’s condition following a telephone referral. (b) Timely consultation and timely responses to telephone referrals from patients and their families. (c) The threshold for determining whether a telephone consultation is adequate or whether a home consultation should be undertaken. (2) A full assessment of the patient’s mental capacity in a situation where they are refusing medical treatment or admission to hospital. (3) Full and proper documentation of the discussions between the doctor and the patient/patient’s family in those circumstances. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Inability of reception staff to interrupt GPs to alert and inform them of changes in a patient’s condition following telephone referrals
Wider context from the report
“(1) Telephone referrals and the lack of an effective system for conveying and responding to information between the caller and the doctor. Specifically, I had concerns about the following aspects: (a) The inability of reception staff to interrupt a GP during surgery for the purposes of alerting and informing the doctor of a change in the patient’s condition following a telephone referral. (b) Timely consultation and timely responses to telephone referrals from patients and their families. (c) The threshold for determining whether a telephone consultation is adequate or whether a home consultation should be undertaken. (2) A full assessment of the patient’s mental capacity in a situation where they are refusing medical treatment or admission to hospital. (3) Full and proper documentation of the discussions between the doctor and the patient/patient’s family in those circumstances. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Failure to fully and properly document discussions with patients or their families
Wider context from the report
“(1) Telephone referrals and the lack of an effective system for conveying and responding to information between the caller and the doctor. Specifically, I had concerns about the following aspects: (a) The inability of reception staff to interrupt a GP during surgery for the purposes of alerting and informing the doctor of a change in the patient’s condition following a telephone referral. (b) Timely consultation and timely responses to telephone referrals from patients and their families. (c) The threshold for determining whether a telephone consultation is adequate or whether a home consultation should be undertaken. (2) A full assessment of the patient’s mental capacity in a situation where they are refusing medical treatment or admission to hospital. (3) Full and proper documentation of the discussions between the doctor and the patient/patient’s family in those circumstances. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Failure to determine an adequate threshold for telephone versus home consultation
Wider context from the report
“(1) Telephone referrals and the lack of an effective system for conveying and responding to information between the caller and the doctor. Specifically, I had concerns about the following aspects: (a) The inability of reception staff to interrupt a GP during surgery for the purposes of alerting and informing the doctor of a change in the patient’s condition following a telephone referral. (b) Timely consultation and timely responses to telephone referrals from patients and their families. (c) The threshold for determining whether a telephone consultation is adequate or whether a home consultation should be undertaken. (2) A full assessment of the patient’s mental capacity in a situation where they are refusing medical treatment or admission to hospital. (3) Full and proper documentation of the discussions between the doctor and the patient/patient’s family in those circumstances. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation
Failure to fully assess patients’ mental capacity when they refuse medical treatment or hospital admission
Wider context from the report
“(1) Telephone referrals and the lack of an effective system for conveying and responding to information between the caller and the doctor. Specifically, I had concerns about the following aspects: (a) The inability of reception staff to interrupt a GP during surgery for the purposes of alerting and informing the doctor of a change in the patient’s condition following a telephone referral. (b) Timely consultation and timely responses to telephone referrals from patients and their families. (c) The threshold for determining whether a telephone consultation is adequate or whether a home consultation should be undertaken. (2) A full assessment of the patient’s mental capacity in a situation where they are refusing medical treatment or admission to hospital. (3) Full and proper documentation of the discussions between the doctor and the patient/patient’s family in those circumstances. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised1

Lack of non-hospital respite care options for mentally ill people in the community

Concerns raised4

Increased risk of self-harm or suicide following adverse experiences of sectioning

Lack of continuity of treatment

Lack of an acute treatment facility for acute admission patients in Powys

Lack of an acute treatment facility for acutely unwell patients in Powys

Concerns raised4

Failure to provide timely ambulance responses to Amber 2 calls

Failure to make timely follow-up calls to update, advise and reassess emergency callers

Lack of clear planning and direction for maintaining and delivering ambulance services

Failure to maintain ambulance service delivery during significant call volumes

Concerns raised1

Lack of an advance warning sign for the approaching left bend

Concerns raised1

Delays in ambulance attendance

Concerns raised4

Inadequate monitoring of INR levels

Inadequate communication about anticoagulation monitoring and potential therapy adjustment

Lack of certainty whether Warfarin was being taken

Failure to admit a patient to hospital when a possible ischaemic leg requires assessment and anticoagulation adjustment

Concerns raised4

Insufficient staffing of Tissue Viability Nurses

Failure to maintain adequate repositioning charts

Failure to maintain adequate pressure ulcer documentation

Lack of integrated skin care across Health Boards and Primary healthcare services

Concerns raised2

Unreliable booking system for community INR testing

Unreliable notification system for omissions by family or carers

Concerns raised3

Insufficient staffing capacity for safe patient oversight

Failure to maintain complete and consistent nursing and clinical records

Failure to undertake nursing observations in accordance with required procedures and guidance

Concerns raised2

Inadequate visibility at the road traffic junction

Absence or inadequacy of filter lanes at the road traffic junction