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 12 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
5 Feb 2026	Kallum Reed 2026-0061 · Lydia Brown Unacceptably long waits for ASD/ADHD services and mental health crisis team gate-keeping failures led to patients being denied crucial in-person assessments and …	London West London	Department of Health and Social … West London NHS Trust	2/2
5 Feb 2026	Sam Dudley 2026-0060 · Anita Bhardwaj Limited and ineffective signage on railway pedestrian gates, especially for earphone users, fails to provide adequate warnings at a critical "decision point."	North West Sefton, St Helens and Knowsley	Level Crossings and Public Safety Level Crossing and Public Safety North West Route Director The Chief Coroner	1/4
4 Feb 2026	Lauren Moret-Dell 2026-0059 · Darren Stewart Hospital staff lacked proficiency in timely TIA Clinic referrals. Additionally, out-of-hours stroke care lacked commissioned stroke consultant input, adversely impacting patient treatment …	East of England Suffolk	Suffolk and North East Essex … West Suffolk NHS Foundation Trust	1/2
4 Feb 2026	Oliver Robinson 2026-0058 · Catherine McKenna A consultant with inadequate expertise prescribed medicinal cannabis based on incomplete information, without consulting existing psychiatrists, obstructing the patient's appropriate psychiatric and …	North West Manchester North	Curaleaf Clinic	1/1
4 Feb 2026	Georgia Scarff 2026-0057 · Darren Stewart School staff unfamiliarity with the safeguarding system led to missed recordings. The lack of a single national safeguarding information management tool for …	East of England Suffolk	Department for Education Minister for Women and Equalities Royal Hospital School	0/3
3 Feb 2026	Ellame Ford-Dunn Prevention of future deaths report 2026-0056 · Joanne Andrews Insufficient Tier 4 Paediatric Mental Health beds lead to long waits, resulting in children with mental health needs being inappropriately held on …	South East West Sussex, Brighton and Hove	NHS England & NHS Improvement	1/1
4 Feb 2026	Joan Read Prevention of future deaths report 2026-0055 · Rachel Knight A single consultant lacking cross-cover for geriatric perioperative care creates a risk of urgent test results being missed during periods of absence.	Wales South Wales Central	[REDACTED}, Chief Executive Cardiff & …	1/1
4 Feb 2026	Ryan Harding Prevention of future deaths report 2026-0054 · David Regan Inadequate prison infrastructure allows illicit materials to enter. Scheduled welfare checks were also frequently delayed or missed due to staffing shortages.	Wales South Wales Central	Governor of HM Prison Parc	1/1
3 Feb 2026	Lyn Maher 2026-0053 · Rachel Knight Community pharmacists in Wales faced confusion regarding clinical checks and patient confidentiality, and had limited access to crucial drug history via the …	Wales South Wales Central	Digital Health and Care, Wales General Pharmaceutical Council Health and Social Care for … NHS England	1/4
1 Feb 2026	Simon Moss 2026-0052 · Xavier Mooyaart Mental health assessments failed to incorporate detailed ambulance records (EPRC) and family contact information, leading to inadequate risk evaluation for suicidal patients …	London Inner South London	NHS England	1/1
3 Feb 2026	Nathan Cyster 2026-0051 · Daniel Howe Hazardous right-turn manoeuvres, absent "left turn only" signage, ineffective road markings, and ambiguous legal guidance for crossing double white lines collectively create …	West Midlands Staffordshire and Stoke-on-Trent	Department of Transport Moss Farm National Highways	3/3
2 Feb 2026	Heather Parkhill 2026-0050 · John Gittens Persistent ambulance delays and resource unavailability continue to put lives at risk, despite ongoing multi-agency efforts to address these long-standing issues.	Wales North Wales (East and Central)	Welsh Ambulance Service NHS Trust	2/1
30 Jan 2026	Pamela George 2026-0049 · Deborah Archer The care home failed to conduct regular blood tests, inadequately managed infections, and lacked clear policies for medical escalation, capacity assessment, and …	South West Devon, Plymouth and Torbay	Cann House Premiere Health Ltd	1/2
2 Feb 2026	Avery Hall 2026-0048 · David Place A GP failed to provide specific advice on Candesartan risks during pregnancy, and the medication remained on repeat prescription, approved without review …	North East Sunderland	Riverview Surgery Royal College of General Practitioners	2/2
28 Jan 2026	Nigel Feckey 2026-0047 · D Hocking The 'Offence Neutrality' policy in prisons, mingling sex offenders with mainstream prisoners, fostered fear, bullying, and self-harm among vulnerable inmates, posing a …	East Midlands Leicester City and South Leicestershire	Ministry of Justice	1/1
18 Dec 2025	Stephen Page 2026-0046 · Ian Potter The electronic sensor system provides only a brief, visual CCTV alert without an audible alarm, making it easily missed by operators and …	South East Kent and Medway	MAPP Hempstead Valley Shopping Centre MAPP	1/3
28 Jan 2026	Akhona Moyo 2026-0045 · Hassan Shah Hospital doctors lack electronic access to primary care medical notes, hindering comprehensive patient treatment and preventing a holistic view of patient medical …	East Midlands Northamptonshire	Department of Health and Social … NHS England Northampton General Hospital	2/3
28 Jan 2026	Patricia Walker 2026-0044 · Sally Robinson Suboptimal staffing levels on Ward 90, caused by recruitment difficulties, increase the risk of patient falls due to insufficient dedicated nursing care.	Yorkshire and the Humber City of Kingston Upon Hull and …	Hull University Teaching Hospital NHS England	2/2
27 Jan 2026	Haaris Bhatti 2026-0043 · Mary Hassell Nightclub staff delayed calling an ambulance for a critically unwell patron, indicating systemic failures in training and culture regarding medical emergency management.	London Inner North London	Fold Nightclub	1/1
27 Jan 2026	Pippa Gillibrand 2026-0042 · Victoria Davies A critical lack of national guidance exists for home births, covering midwife training, competency, staffing, equipment, and transfer thresholds, alongside an absence …	North West Cheshire	Department of Health and Social … National Institute for Health and … NHS England Secretary of State for Health …	4/4