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 14 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
15 Jan 2026	Margaret Grimsley 2026-0022 · John Ellery The apparent absence or non-use of an upper alarm setting on bedside oxygen meters risks over-oxygenation, with unclear policies on its implementation …	West Midlands Shropshire, Telford and Wrekin	Shewsbury and Telford Hospital Trust	1/1
14 Jan 2026	Oliver Long 2026-0021 · Laura Bradford The self-exclusion scheme (GamStop) fails to protect individuals from unlicenced overseas gambling sites, which target vulnerable users. There is a critical lack …	South East East Sussex	Department for Digital Culture, Media … Department for Education Department of Health and Social … Gambling Commission	4/4
14 Jan 2026	Stephen Taylor 2026-0020 · Sarah Clarke Multiple services failed to coordinate risk escalation for escalating mental distress, relying on patient denial despite high-risk indicators. Urgent mental health referrals …	South East Kent and Medway	Kent and Medway Mental Health … Vita health Group : Kent …	2/2
14 Jan 2026	Dorothy Hoyberg 2026-0019 · Melanie Lee Extreme pressure on ambulance services, operating at REAP Level 4, resulted in severe delays, unmet targets, and inability to make welfare calls, …	London Inner North London	Department of Health and Social …	1/1
13 Jan 2026	Peter Thompson 2026-0018 · Sarah Huntbach Care home staff failed to perform routine blood sugar tests on a diabetic resident, delaying critical diagnosis. A lack of formal shift …	East Midlands Derby and Derbyshire	Bank Close House Residential Care …	1/1
13 Jan 2026	Heidi Williams 2026-0017 · Anne Pember Evidence showed the deceased ordered numerous tablets from an individual linked to known addresses, but Essex Police have refused Northamptonshire Police's request …	East Midlands Northamptonshire	Essex Police	1/1
13 Jan 2026	Rory Williams 2026-0016 · Kate Robertson The gastroenterology/endoscopy service suffers from critical staffing shortages, inadequate infrastructure, and excessively long waiting times. These systemic failures are not adequately reflected …	Wales North Wales (East and Central)	Betsi Cadwaladr University Health Board	1/1
1 Dec 2025	Stuart Berry 2026-0015 · Sean Horstead Multiple failures by mental health services and serious deficiencies in prison suicide risk assessment, including poor ACCT completion, inadequate observations, and accessible …	East of England Essex	Essex Partnership University NHS Foundation … HCRG HMPPS MoJ	2/4
1 Sep 2025	Ayan Sediqi 2026-0014 · Jayne Wilkes Dangerous road conditions, including ungritted ice and flowing water, were not addressed despite public reports. The existing reporting systems for road faults …	East Midlands Greater Lincolnshire	Lincolnshire County Council Lincolnshire Police National Highways Midlands region	3/3
1 Dec 2025	Amy Pugh 2026-0013 · Paul Marks Clinical staff could not access important mental health records from partner institutions, compromising the patient's assessment and subsequent management.	Yorkshire and the Humber East Riding and Hull	NHS England	1/1
1 Jul 2025	Joshua Allcock 2026-0012 · Zafar Siddique Inconsistent national guidance for autism diagnosis hindered specialist dietician referrals for ARFID, while the insensitive Capillary Refill Time test provided misleading reassurance …	West Midlands Black Country	Birchill’s Health Centre NHS England (Reg 28 Reports) Walsall Healthcare NHS Trust Walsall Local Authority	5/4
1 Dec 2025	Warren Green 2026-0011 · Jeane Mellani High-risk self-harm patients could leave the acute ward without assessment or staff knowledge. The Mental Health Liaison Service lacks clear escalation criteria …	East of England Essex	Essex Partnership University NHS Trust Mid & South Essex NHS …	2/2
1 Sep 2025	Sarah Heaver 2026-0010 · Sarah Clarke Critical neurological investigations and structured observations were omitted for a low GCS patient, compounded by inconsistent medical records. Additionally, patients are discharged …	South East Kent and Medway	East Kent Hospitals University NHS … Kent and Medway NHS and …	2/2
8 Jan 2026	Jean Waldron 2026-0009 · David Reid An agency team leader disregarded clear instructions by providing inappropriate wound care, suggesting inadequate training on care limits and adherence to specialist …	West Midlands Worcestershire	Ignite Health and Homecare Services	1/1
3 Sep 2025	Lucy-Anne Dyson 2025-0451 · Darren Stewart A lack of national interface for safeguarding system communication between schools and agencies, coupled with inconsistent referral guidance, risks missed or inadequate …	South East Hampshire, Portsmouth and Southampton	Department for Education Women and Equalities	1/2
8 Jan 2026	Drew Greaves-Pimblett 2026-0008 · Anita Bhardwaj National telephone triage pathways lack adequate guidance for call handlers on probing questions for critical symptoms like breathing and body temperature, hindering …	North West Sefton, St Helens and Knowsley	NHS England	1/1
8 Jan 2026	David Dugdale 2026-0007 · Rachel Redman Inadequate pain management, lack of nutritional support, and severe neglect of a pressure sore, exacerbated by nursing staff ignoring carers' concerns, led …	South East East Sussex	East Sussex Healthcare NHS Trust	1/1
6 Jan 2026	Theo Tuikubulau 2026-0006 · Louise Wiltshire Two distinct triage systems for 999 and 111 calls create a two-tiered ambulance categorisation for similar urgent breathing complications, potentially delaying critical …	South West Devon, Plymouth and Torbay	NHS England	2/1
6 Jan 2026	Robert Gracey 2026-0004 · Paul Smith Despite national recommendations, Lincolnshire lacks an established protocol to treat suspected Acute Behavioural Disturbance (ABD) as a medical emergency. The NHS Pathways …	East Midlands Greater Lincolnshire	East Midlands Ambulance Service NHS … Lincolnshire Police NHS England	2/3
5 Jan 2026	Suzanne Pemberton 2026-0003 · Sean Horstead The hospital lacks any specialist dietetic service outside weekday working hours, risking delays in crucial nutritional interventions like naso-gastric feeding and potential …	East of England Essex	East Suffolk and North Essex …	1/1