Source · Prevention of Future Deaths

Prevention of Future Deaths Reports

Browse 6,383 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.

Response tracker Organisations Advanced search

Keyword

Browse by year

Browse by region

Sort

Reports

6,383 reports · Page 1 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
19 May 2026	Catherine Morgan – Prevention of future deaths report The Trust's risk assessments for patient leave were inconsistent with guidelines, and systems for safeguarding and monitoring voluntary patients were inadequate. The …		No addressees parsed	2/0
28 May 2026	Alex Robinson- Prevention of future deaths report Conflicting information regarding a mental health liaison team referral meant a patient did not receive an assessment, despite the service being 24/7 …		No addressees parsed	1/0
18 May 2026	Rebecca Mclellan- Prevention of future deaths report A patient was without a dedicated care co-ordinator for nine weeks due to staff shortages and the absence of a documented system …	East of England Suffolk	1. Norfolk and Suffolk NHS … report, namely by 18th July … You are under a duty …	2/3
18 Oct 2024	Robin Ward – Prevention of future death report Increasing pressures on acute mental health bed provision locally and nationally lead to the use of crisis houses, which lack the clinical …		1 Secretary of State for … Secretary of State for Health …	1/2
20 May 2026	Ricky Crosher and Matthew Osborne- Prevention of future deaths … 2026-0277 The facility had an under-resourced Safer Custody function, lacked robust systems for managing telephone lines and learning from deaths, and the Care …		No addressees parsed	2/0
21 May 2026	Patricia Barnett- Prevention of future deaths report A resident with reduced mobility and cognitive impairment, at high risk of falls, was left unsupervised in the lounge area, raising concerns …		No addressees parsed	1/0
20 May 2026	Isaac Arrowsmith Concerns include insufficient clinician knowledge of clot risks in rare conditions and a lack of a clear process for seeking specialist advice. …		No addressees parsed	1/0
3 Jun 2026	Jack Burton- Prevention of future deaths report Lack of clear guidance for doctors on the relevance of smoking reduction versus cessation was noted, alongside no standardised practice for discussing …	West Midlands Worcestershire	No addressees parsed	1/0
8 May 2026	Garth Pretorius 2026-0273 · Paul Marks The Emergency Department uses two different triage systems simultaneously, and there are insufficient resources to universally adopt and train staff on the …	City of Kingston upon Hull and …	1. Chief Executive HUTH Chief Executive HUTH2.CORONERI am Professor …	1/2
12 Jun 2024	Beryl Dandridge 2026-0272 · Nicholas Graham Conflicting clinical views on echocardiogram necessity for vulnerable patients before surgery and unclear responsibility for expediting scans were noted. The Structured Mortality …	South East Oxfordshire	Oxford University Hospitals NHS Foundation …	1/1
19 May 2026	Najib Naagi 2026-0271 · Mary Hassell Inaccurate patient observation times were recorded, leading to incorrect medical records and potentially obstructing learning from deaths. The clinical support worker initially …	London Inner North London	North London NHS Foundation Trust	1/1
11 May 2026	Trevor Evans 2026-0270 · Gareth Lewis Mental health risk assessments relied heavily on patient self-reporting, with insufficient medical record review and proactive investigation into available background information. Assessors …	Carmarthenshire and Pembrokshire	Hywel Dda University Health Board	1/1
7 May 2026	Elsie Jones 2026-0269 · Louise Hunt Lengthy delays in securing funding and suitable specialist placements for severe dementia patients mean prolonged hospital stays. Acute wards cannot always adequately …	West Midlands Birmingham and Solihull	Birmingham and Solihull Integrated Care … Department of Health and Social …	2/2
8 May 2026	Ollie Lee 2026-0268 · Hannah Berry Poor communication and engagement between agencies, especially early help and CAMHS, led to missed opportunities for support. Important discussions were not recorded, …	Yorkshire and the Humber South Yorkshire (West)	Barnsley Community Academy Barnsley Metropolitan Borough Council South West Yorkshire Partnership NHS …	4/3
14 May 2026	Natalia Cestaro 2026-0267 · Linda Lee Risk assessments for impulsive ingestion are not proactively broad enough. Concerns exist regarding the consistency of liaison between mental health and acute …	West Midlands Coventry and Warwickshire	Coventry and Warwickshire Partnership NHS … University Hospitals Coventry and Warwickshire …	2/2
2 Jul 2024	Caroline Harris 2026-0266 · Nicholas Graham Information about mental health deterioration was not shared with the appropriate mental health team, who would have intervened urgently. This was due …	South East Oxfordshire	Oxfordshire County Council	1/1
27 Apr 2026	Michael Chadwick 2026-0265 · Nathanael Hartley Clinicians did not advise a patient with cough syncope to stop driving or notify the DVLA on multiple occasions. There is a …	East Midlands Nottingham and Nottinghamshire	Middleton Lodge Practice Nottingham University Hospitals NHS Trust Sherwood Forest Hospitals NHS Trust	3/3
22 May 2026	David Smart 2026-0262 · Joanne Andrews The emergency department continues to use corridors for patient care when at capacity, despite ongoing efforts to improve patient flow and reduce …	South East West Sussex, Brighton and Hove	Department of Health and Social … NHS England & NHS Improvement University Hospitals Sussex NHS Foundation …	3/3
19 May 2026	Patricia Hazell 2026-0254 · Nicholas Graham Concerns are raised about wheelchair access doors on coaches potentially opening from the exterior, with existing warnings to passengers inside not always …	South East Oxfordshire	Driver and Vehicle Standards Agency	1/1
6 May 2026	Lisa Townsend 2026-0263 · Patricia Morgan The coroner noted the absence of clear guidance and protocol for referrals between a local hospital and a tertiary centre regarding Hepato-Pancreato-Biliary …	Wales South Wales Central	Cabinet Secretary for Health and … Cardiff and Vale University Health … Cwm Taf Morganwg University Health …	3/3