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 15 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
5 Jan 2026	Adam Hussain 2026-0002 · Elizabeth Didcock The urgent care pathway poorly serves serious systemic illnesses like sepsis, with critical patient information not reliably used by ambulance staff, leading …	East Midlands Nottinghamshire	East Midlands Ambulance Service NHS … NHS England Nottingham and Nottinghamshire Integrated Care … Nottingham Emergency Medical Service	4/4
5 Jan 2026	Jake Hartwright 2026-0001 · Elizabeth Didcock The urgent care pathway poorly serves non-immediately life-threatening systemic illnesses, as detailed 111 information is unreliably used by EMAS, families are uninformed …	East Midlands Nottinghamshire	East Midlands Ambulance Service NHS … NHS England Nottingham and Nottinghamshire Integrated Care … Nottingham Emergency Medical Service	4/4
6 Jan 2026	Mohammed Choudhury 2026-0005 · Emma Whitting Inadequate management of a patient's paranoid schizophrenia included failure to address non-concordance with anti-psychotic medication and withdrawal of medication support without GP …	East of England Bedfordshire and Luton	East London NHS Foundation Trust	1/1
29 Dec 2025	Fallon Adams 2025-0647 · Simon Milburn There was a failure to provide specific warnings to the prisoner about the dangers of combining prescribed sedative medications with illicit drugs, …	East of England Cambridgeshire and Peterborough	Northamptonshire Healthcare Foundation Trust	1/1
18 Dec 2025	John Oates 2025-0646 · Kirsty Gomersal Manufacturing defects in widespread porcelain tension disc insulators cause failures that can lead to dangerous low-hanging power lines, a risk compounded by …	North West Cumbria	Electricity Networks Association	1/1
29 Dec 2025	Brian Mitchell 2025-0645 · Graeme Irvine No clear evidence exists that risks of fatal harm on railway tracks have been mitigated, with recommended detection technology unimplemented and training …	London East London	Department for Transport Mayor of London Transport for London	2/3
28 Dec 2025	Mohamed Abdisamad 2025-0644 · Anton van Dellen There is a complete absence of regulation for Non-Therapeutic Male Circumcisions, including no requirements for training, accreditation, consent, record-keeping, infection control, or …	London West London	Department for Health and Social …	2/1
24 Dec 2025	Alan Baker 2025-0643 · Johanna Thompson There is no mandatory requirement for LGVs to have reversing cameras or for existing cameras to be maintained, increasing the risk of …	East of England Norfolk	Driver and Vehicle Standards Agency	1/1
23 Dec 2025	Colin Brown 2025-0642 · Gillian Kane Crucial patient information, such as choking risk, was not reliably transferred with the patient or consistently communicated during hospital handovers, compounded by …	Yorkshire and the Humber North Yorkshire and York	York and Scarborough Teaching Hospitals … YAS Legal	2/2
22 Dec 2025	Wendy Eyles 2025-0641 · Hassan Shah No protocol exists for managing patients under both NHS and private psychiatry, leading to critical medication changes not being communicated, creating confusion …	East Midlands Northamptonshire	Northamptonshire Healthcare Foundation Trust Northamptonshire Integrated Care Board	0/2
22 Dec 2025	Winifred Wardle 2025-0640 · Adrian Farrow The hospital lacks a clear multi-disciplinary protocol for CT scan requests, with unclear escalation lines when requests are rejected and inadequate record-keeping …	North West Manchester South	Tameside and Glossop Integrated Care …	0/1
19 Dec 2025	Ramona Harbott 2025-0637 · Susan Ridge Care home staff failed to adhere to pressure sore prevention policies, leading to inadequate repositioning, poor skin monitoring, and severe, undocumented pressure …	South East Surrey	Care Quality Commission, Barchester Health …	2/1
19 Dec 2025	Jason White 2025-0638 · N Mundy Antipsychotic medication was abruptly ceased, and the daily monitoring plan was not followed, creating an unmanaged risk of relapse and serious deterioration …	Yorkshire and the Humber South Yorkshire East	Sheffield Health Partnership, University NHS …	1/1
10 Dec 2025	Mesut Olgun 2025-0618 · David Reid The coroner raises concerns that the prison's designated 'safer cells' are not located within the segregation unit, leading to high-risk prisoners being …	West Midlands Worcestershire	HM Prison and Probation Service Probation and Reducing Offending, Ministry …	1/2
12 Feb 2025	Brigitte Favre 2025-0639 · Darren Stewart A lack of weekend oncology support hindered safe discharge planning, and poor emergency department record management meant critical chemotherapy history was missed …	East of England Suffolk	West Suffolk Hospital, Suffolk and …	1/1
14 Oct 2025	Paula Doreen 2025-0511 · Liliane Field National risk of concurrent paracetamol prescriptions due to prescribing system deficiencies and inadequate assessment of patient confusion. Inconsistent management of therapeutic excess …	London Inner South London	Royal Pharmaceutical Society (RPS) Lewisham and Greenwich NHS Trust Medicine and Healthcare Product Regulatory … NHS England	5/6
23 Oct 2025	Lynn Silcock 2025-0636 · Heath Westerman A patient was discharged by gastroenterology without cardiology consultation or follow-up, due to a lack of communication and document exchange between teams, …	West Midlands Shropshire, Telford & Wrekin	NHS England Shrewsbury and Telford NHS Hospital …	2/2
9 Dec 2025	Urielle Kuyenga 2025-0635 · Graeme Irvine A critical communication breakdown between hospital and GP regarding medication monitoring, combined with repeated failures by GPs to check clinical records, left …	London East London	Barts Health NHS Trust Department of Health and Social … East London Cooperatives Ltd Maylands Healthcare Surgery	4/4
17 Dec 2025	Debapriya Ghosh and David Ward 2025-0634 · Fiona Wilcox Insufficient staffing and bed spaces in A&E resulted in frail elderly patients being unsupervised, leading to unwitnessed falls, fatal head injuries, and …	London Inner West London	Department of Health and Social …	1/1
18 Dec 2025	Edward Jones 2025-0633 · Oliver Longstaff The absence of a nationally validated sepsis screening tool for Paediatric Emergency Departments and inconsistent application of the trust's own tool across …	Yorkshire and the Humber West Yorkshire Eastern	National Institute for Health and …	1/1