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 |
|---|---|---|
| 23 Jan 2026 |
Roger Leadbeater
2026-0041 · Tanyka Rawden
Inadequate and unrecorded handovers between police forces and a mental health trust meant critical risk information about a patient was lost, impacting …
|
2/2 |
| 27 Jan 2026 |
Lucy Thornton
2026-0040 · Jason Pegg
Ambulance call handler training was inadequate regarding Category 1 response criteria for hanging incidents, and procedures for obtaining further information from callers …
|
1/1 |
| 21 Jan 2026 |
George Ritchie
2026-0039 · David Reid
The nursing home had inadequate falls risk assessments and care plans, lacking oversight and supervision. Additionally, low night-time staffing was not addressed, …
|
1/1 |
| 21 Jan 2026 |
George Ritchie
2026-0039-wp117787 · David Reid
The nursing home had inadequate falls risk assessments and care plans, lacking oversight and supervision. Additionally, low night-time staffing was not addressed, …
|
0/1 |
| 20 Oct 2025 |
Scott Berry
2026-0038 · Sarah Middleton
Imprisonment for Public Protection (IPP) prisoners face profound hopelessness and mental health suffering due to indefinite detention and lack of access to …
|
1/2 |
| 23 Jan 2026 |
Dennis Price
2026-0037 · N Mundy
Failures in inpatient post-fall reviews, unclear neurological observation plans, and inefficient electronic system escalations compromised patient safety.
|
1/1 |
| 23 Jan 2026 |
Jean Groves
2026-0036 · Johanna Thompson
Emergency responders assisting ambulance services are not provided with crucial access details for vulnerable patients, potentially endangering lives during medical interventions.
|
2/2 |
| 22 Jan 2026 |
Tamara Logan
2026-0035 · Alison Mutch
An incorrect benefits assessment, uncorrected by review, significantly impacted the deceased. Additionally, standard letters were sent despite recognised vulnerabilities, without attempting to …
|
1/1 |
| 22 Jan 2026 |
Clive Hyman
2026-0034 · Sarah Bourke
Patient information leaflets for Apixaban do not adequately advise on actions following head trauma, risking delayed medical intervention for intracranial bleeds in …
|
3/3 |
| 21 Jan 2026 |
Dhananji Dona
2026-0033 · Emma Serrano
The hospital failed to implement the specialist National Early Warning Score matrix for prenatal women across all departments, risking inadequate monitoring without …
|
2/2 |
| 28 Oct 2025 |
Shannon Lee
2026-0032 · Zafar Siddique
There is persistent staff confusion regarding the exact timing of 15-minute observations, with no clear national standard, risking inconsistent patient monitoring.
|
1/2 |
| 21 Jan 2026 |
Sidra Aliabase
2026-0031 · Fiona Wilcox
Failures included not expediting Long QT Syndrome diagnosis, inadequate communication of expert opinion, a five-fold medication overdose, and a significant delay in …
|
1/2 |
| 19 Jan 2026 |
Martin Bryant
2026-0030 · Rebecca Mundy
Mental health crisis patients face dangerously long waits in open reception areas due to a severe lack of local and national mental …
|
2/2 |
| 20 Jan 2026 |
Linda Fury
2026-0029Deceased · Chris Morris
The Trust's investigation into Linda's discharge was insufficient, failing to adequately analyze the lack of local beds, decision-making process, and capacity assessment. …
|
1/1 |
| 16 Jan 2026 |
Wayne Walton
2026-0028 · Deborah Lakin
Inpatient staff lacked awareness of Home Treatment Team policies, leading to inadequate risk assessments and safety plans. There is also no guidance …
|
1/1 |
| 7 Oct 2025 |
Angela Thompson
2026-0027 · Paul Marks
A lack of liaison between prison and community psychiatric services for released prisoners with ongoing mental health issues, especially when geographically distant, …
|
2/1 |
| 23 Oct 2025 |
Rashida Sultana
2026-0026 · Zafar Siddique
Nursing staff lacked clarity on when to call the Emergency Medical Response Team for patients with a DNAR. There was also an …
|
1/2 |
| 15 Jan 2026 |
Matilda Pomfret-Thomas
2026-0025 · Henry Charles
A lack of regulation, registration, and clear guidance for doulas creates confusion about their role, risks them working outside clinical boundaries, and …
|
4/3 |
| 15 Jan 2026 |
Ronald Nelson
2026-0024 · Sarah Wood
Concerns remain regarding poor record keeping and inadequate compliance with care plans, which pose a risk to future patient safety.
|
2/2 |
| 1 Dec 2025 |
Mark Vidler
2026-0023 · Ian Potter
Mental health services suffered from process-driven care, unclear clinical decision-making in triaging referrals, and pre-determined discharge decisions lacking receiving team involvement. The …
|
1/1 |