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.

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6,383 reports · Page 10 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
21 Nov 2025	Timothy Reading 2026-0101 · James Puzey The lack of formal, agreed S.117 plans for mental health discharge creates disjointed patient support. There is also no national guidance clarifying …	West Midlands Worcestershire	Birmingham and Solihull Mental Health … NHS England	2/2
19 Feb 2026	Rajwinder Singh 2026-0100 · Bernard Richmond HMP Wandsworth lacks mandatory ACCT refresher training for prison officers and equivalent training for agency healthcare staff, and offers no training in …	London Inner West London	HMP Wandsworth NHS England Oxleas	3/3
5 Dec 2025	Andrew Hughes 2026-0099 · Alison Mutch The 'Right Care Right Person' system lacks clarity on how concerned families can access emergency mental health services, and there is insufficient …	North West Manchester South	Deputy Mayor of Greater Manchester Greater Manchester Integrated Care Board	3/2
17 Feb 2026	Martin Ormond 2026-0098 · Alan Wilson A GP made critical decisions without full information, and there was no effective process to ensure updated or additional reports reached the …	North West Blackpool & Fylde	Broomwell Health Watch LYD Crescent Surgery	2/2
17 Feb 2026	Edward Hands 2026-0097 · Bina Patel Confusion and differing policies between prison and healthcare staff regarding prisoners under the influence led to inadequate observation, failed recognition of clinical …	East of England Bedfordshire and Luton	HMP Bedford Ministry of Justice Northamptonshire Healthcare Foundation Trust	3/3
13 Feb 2026	Edward Jones 2026-0096 · Oliver Longstaff There is no nationally validated sepsis screening tool for Paediatric Emergency Departments, and the trust's own tool lacks consistent application between departments.	Yorkshire and the Humber West Yorkshire East	National Institute for Health and … NHS England	1/2
16 Feb 2026	Geoffrey Gudgeon 2026-0095 · Andrew Cox There is a significant capacity issue in Cornwall concerning the timely admission and treatment of stroke patients, leading to delays in accessing …	South West Cornwall & the Isles of Scilly	Cornwall & Isles of Scilly … Royal Cornwall Hospitals NHS Trust	2/2
17 Feb 2026	Benjamin Websdale 2026-0094 · Penelope Schofield There's no national recording of police officer suicides during misconduct investigations, preventing identification of risk and support needs. Also, not all police …	South East West Sussex, Brighton and Hove	National Police Chiefs Council	1/1
12 Feb 2026	Rita Thomas and Christine Dale 2026-0093 · Robert Cohen The junction design, coupled with the national speed limit on the A684, provides drivers with insufficient reaction time, increasing the risk of …	North West Cumbria	National Highways	2/1
2 Feb 2026	Scott Taylor 2026-0092 · Sonia Hayes Ambulance service triage for Acute Behavioural Disturbance suffered from incorrect call categorisation and confusing, inconsistent training. Police training for Special Constables on …	East of England Essex	Association of Ambulance Chief Executives East of England Ambulance NHS … Essex Police	3/3
9 Feb 2026	Janet Tripp 2026-0091 · Guy Davies Insufficient evidence shows that previously identified hospital failings have been addressed, indicating ongoing risks to patient safety.	South West Cornwall & the Isles of Scilly	Royal Cornwall Hospital	1/1
10 Feb 2026	Liam Sutton 2026-0090 · Catherine Wood Persistent delays in discharging medically fit patients due to inadequate community care provision block acute beds, leading to dangerous overcrowding in emergency …	South East Kent and Medway	Department of Health and Social … Kent and Medway Integrated Care … Kent County Council Medway Council	3/4
28 Nov 2025	Gurkirat Singh 2026-0089 · Zafar Siddique A dangerous road stretch lacks pedestrian crossings, has obscured visibility from parked vehicles, and suffers from poor street lighting and absent central …	West Midlands Black Country	Highways Department Sandwell Local Authority	1/2
10 Feb 2026	Barbara Wingate 2026-0088 · Catherine Wood Persistent issues with patient discharge delays due to inadequate community care provisions cause emergency department overcrowding and restrict timely access to acute …	South East Kent and Medway	Department of Health and Social … Kent and Medway Integrated Care … Kent County Council Medway Council	5/4
12 Feb 2026	James Fitzpatrick 2026-0087 · Rachael Griffin A lack of national and local written guidance for patient handovers between staff and wards leads to incorrect or incomplete information being …	South West Dorset	Dorset Healthcare University NHS Foundation … National Institute for Health and … General Medical Council (GMC) Nursing and Midwifery Council (NMC)	4/4
11 Feb 2026	Chloe Ulett 2026-0086 · Emma Brown There is a lack of routine ammonia testing for acutely confused adults, and current RCEM guidelines for metabolic disorders are not well-embedded …	West Midlands Birmingham and Solihull	Faculty of Intensive Care Medicine Royal College of Emergency Medicine … Royal College of Midwives Royal College of Obstetricians and …	5/4
6 Feb 2026	Linda Brooks 2026-0085 · Deborah Archer The Trust showed a lack of staff training in escalating serious clinical incidents, no effective process for reviewing notes to identify issues, …	South West Devon, Plymouth and Torbay	Torbay and South Devon NHS …	1/1
9 Feb 2026	Brody O’Brien 2026-0084 · Emma Mather An unsecured ligature point was accessible, and emergency services faced difficult, treacherous access to the location, hindering timely intervention.	North West Lancashire and Blackburn with Darwen	Health and Safety Executive Rossendale Borough Council	2/2
6 Feb 2026	Stephen Rhodes 2026-0083 · Zafar Siddique A GP practice failed to adequately scrutinise abnormal blood test results, missing a critical referral for specialist cardiac assessment despite clear laboratory …	West Midlands Black Country	NHS England Quarry Bank Medical centre	2/2
10 Feb 2026	Samuel Dickinson 2026-0082 · Michael Pemberton Gaps in firearms legislation mean licence holders are not required to self-report medical conditions, and GPs are not obligated to record licences …	North West Manchester West	Department of Health and Social … Home Office	2/2