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.
Reports
| Date | Report | Responses identified |
|---|---|---|
| 9 Feb 2026 |
Helen Patching, Rachael Patching and Corey Longdon
2026-0081 · Rachel Knight
Inadequate signage fails to address significant falling risks in 'Waterfall Country', and poor mobile phone signal hinders emergency services' response times.
|
5/5 |
| 10 Feb 2026 |
David Thompson
2026-0080 · Alison Longhorn
Police widely use the term 'suicidal ideation' which is not understood by the public or consistently by officers, risking critical information being …
|
1/1 |
| n/a |
Ellen Taylor
2026-0079 · Sarah Middleton
Hospital staff failed to recognise a patient's altered anatomy from previous gastric surgery during nasogastric tube insertion due to missing guidelines and …
|
1/1 |
| 8 Feb 2026 |
Elise Sebastian
2026-0078 · Sonia Hayes
Mental health ward staff lacked neurodiversity training and were inexperienced, leading to insufficient staffing, missed patient observations, and incorrect medication charting.
|
1/1 |
| 7 Feb 2026 |
Janet Springall
2026-0074 · Alan Anthony
Hospital emergency departments face significant pressures, causing unwell patients to remain in ambulances and delaying critical treatment, which reduces survival chances.
|
2/2 |
| 9 Feb 2026 |
Gareth Chumber-Kelly
2026-0073 · Jonathan Stevens
Inefficient prison reception processes lead to lost critical prisoner information, and suicide/self-harm training for staff was suspended despite high rates of suicidal …
|
2/4 |
| 6 Feb 2026 |
Mansoor Zaman
2026-0072 · Graeme Irvine
Nursing staff failed to instigate MHA authorisations, adequately document care, reappraise risk after violent behaviour and absconding, and promptly report a missing …
|
3/2 |
| 6 Feb 2026 |
Emmett Morrison
2026-0071 · David Reid
HMP Long Lartin suffered from a continued influx of illicit drugs. There were also systemic failures in the ACCT process, with no …
|
1/2 |
| 2 Feb 2026 |
Mia Lucas
2026-0070 · Tanyka Rawden
A lack of national guidance for clinicians on considering and diagnosing Autoimmune Encephalitis creates a risk of missed diagnoses and future deaths.
|
4/1 |
| 6 Feb 2026 |
Roger Smith
2026-0069 · Darren Stewart
Ineffective electronic patient records failed to flag critical medication information, and poor communication led to anticoagulation being administered against patient wishes, without …
|
1/1 |
| 7 Nov 2025 |
Anthony Card
2026-0068 · Peter Taheri
There is no formal mechanism for police to share medium-risk mental health information with care providers, even with consent. This prevents crucial …
|
2/2 |
| 7 Feb 2026 |
Bonita Cleary
2026-0067 · Alan Wilson
A lack of awareness among care staff regarding when CPR should be attempted risks potentially reversible deaths in vulnerable residents.
|
2/2 |
| 6 Feb 2026 |
Michaela Finch
2026-0064 · Timothy Brennand
Hospital discharge decisions failed to adequately assess a patient's significant mental health deterioration and suicidal ideation, attributing issues solely to alcohol misuse …
|
2/2 |
| 9 Feb 2026 |
Josh Tarrant (3)
2026-0077 · Scott Matthewson
Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged …
|
1/1 |
| 9 Feb 2026 |
Josh Tarrant (2)
2026-0076 · Scott Matthewson
Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged …
|
0/2 |
| 9 Feb 2026 |
Josh Tarrant (1)
2026-0075 · Scott Matthewson
Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged …
|
2/1 |
| 6 Feb 2026 |
Paul Thompson
2026-0066 · Darren Stewart
HMP Norwich had inadequate arrangements for releasing prisoners needing mental health care, leading to failures in ensuring follow-up and timely information sharing …
|
1/1 |
| 14 Jan 2026 |
Mark Turner
2026-0065 · Emma Serrano
There is a critical absence of local or national guidance for managing the steps to be taken when a high serum level …
|
2/2 |
| 5 Feb 2026 |
Della Calvey
2026-0063 · Caroline Saunders
Unsafe practice of routinely downgrading NEWS scores for all COPD patients without knowing individual baseline saturations leads to inadequate clinical assessments.
|
2/2 |
| 5 Feb 2026 |
Bruce Caulfield
2026-0062 · Chris Morris
Concerns include delays in medical reviews after family concerns, insufficient intentional rounding impacting vulnerable patient hydration, and inconsistent communication practices for fall …
|
1/1 |