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 16 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
17 Dec 2025	Dorothy Macdonald 2025-0632 · David Lewis Nursing home staff repeatedly and incorrectly assessed a vulnerable patient's falls risk as low, indicating ineffective training in risk assessment and a …	North West Liverpool and Wirral	Westwood Hall Nursing Home	1/1
17 Sep 2025	Brian Davies 2025-0631 · Aled Gruffydd The investigation into a domestic explosion was compromised by police disposing of critical debris. There was no understanding of evidence preservation or …	Wales Swansea Neath & Port Talbot	HSE South Wales Police	2/2
17 Dec 2025	Valerie Gibson 2025-0630 · David Place Staff confusion regarding medication dispensing and administration, inadequate checking of patient possessions, and inconsistent electronic record-keeping posed risks of over/under medication and …	North East Sunderland	Cumbria, Northumberland, Tyne and Wear …	1/1
15 Dec 2025	Anthony Lodge 2025-0669 · Rebecca Sutton Urine sample bottles lacked expiry dates, resulting in the use of out-of-date containers and subsequent delays in laboratory processing, posing a risk …	North East County Durham and Darlington	Internation Scientific Supplies Ltd	1/1
16 Dec 2025	Philip Hoggarth 2025-0628 · Caroline Saunders A lack of consistent guidelines and processes for pre-operative iron administration to chronically anaemic patients, alongside no funding agreement, risks damaging delays …	Wales Gwent	Aneurin Bevan University Health Board	1/1
16 Dec 2025	Richard Haddock 2025-0627 · Alison Longhorn Police processes failed to notify the Firearms Licensing Department of a prosecution, and the department did not check PNC records, leading to …	South West County of Devon, Plymouth and Torbay	Devon & Cornwall Police	1/1
15 Dec 2025	Lee Eustace 2025-0626 · Louise Wiltshire An insufficient feeding protocol likely contributed to death, compounded by failures to raise a Datix, send a Duty of Candour letter, and …	South West County of Devon, Plymouth and Torbay	University Hospitals Plymouth NHS Trust	1/1
15 Dec 2025	Sundeep Ghuman 2025-0625 · David Manknell Systemic misunderstanding of the CSRA policy for prisoners posing racist risks led to incorrect 'standard risk' categorization instead of 'high risk,' reflecting …	London London Inner South	HMP Belmarsh Ministry of Justice	1/2
11 Dec 2025	Katherine Wright 2025-0624 · Nicholas Graham Police lack structured training and clear guidance for conducting adequate searches in missing person cases, and there are no protocols for officers …	South East Oxfordshire	Thames Valley Police	1/1
11 Dec 2025	Izzah Ali 2025-0623 · Andrew Cox Healthcare professionals failed to inquire about the contents of 'bottle-fed' milk and did not use interpreters for a non-English speaking mother, reflecting …	South West Cornwall and the Isles of Scilly	Cornwall Council Cornwall Partnership NHS Foundation Trust ICB Royal Cornwall Hospital	3/4
11 Dec 2025	Izzah Ali 2025-0622 · Andrew Cox The 'Essential Guide to feeding your Baby' is inadequate as it fails to explicitly warn against giving cow's milk to infants under …	South West Cornwall and the Isles of Scilly	Education and Children’s Community Health	0/1
11 Dec 2025	David Langford 2025-0621 · Kate Robertson Poor visibility at a dangerous road junction, caused by overgrown foliage, a dull mirror, and old railings, is exacerbated by an inappropriate …	Wales North Wales (East and Central)	Conwy County Borough Council Road (Highways Safety) related deaths Wales prevention of future deaths …	1/3
8 Dec 2025	Matilda Seccombe and Harry Purcell 2025-0612 · Linda Lee Current licensing arrangements for new drivers inadequately address risks from multiple passengers, vehicle loading, and rural road conditions. Insurers also lack consistent …	West Midlands Coventry and Warwickshire	Association of British Insurers Brake Chartered Insurance Institute Department for Transport	5/7
11 Dec 2025	Ashana Charles 2025-0620 · Andrew Harris Critical medical equipment was not retained for forensic investigation, and there is inconsistent national guidance on parenteral nutrition filters, alongside fragmented risk …	London South London	NHSE NHS England [REDACTED], Chief Executive, Medicines and … [REDACTED], Chief National Medical Examiner, …	1/4
9 Oct 2025	Stella LeClaire 2025-0619 · Christopher Williams The rising number of deaths from a substance sold for suicide raises concerns, emphasizing the need for routine toxicological analysis to improve …	East Midlands Northamptonshire	Secretary of State for Health … Secretary of State for the …	1/2
n/a	Dominic Philip 2025-0617 · Hassan Shah The hospital lacked pre-screening for contrast allergies, and Lidocaine was inexplicably present in an allergic patient, raising concerns about medication contamination or …	East Midlands Northamptonshire	Medicines and Healthcare Products Regulatory … Royal College of Radiologists Department of Health and Social … University Hospitals of Northamptonshire NHS …	4/4
n/a	John Alston 2025-0616 · Kate Bisset Confusion and delays in identifying the correct Integrated Care Board (ICB) responsible for commissioning a patient's care led to delays in accessing …	North West Lancashire and Blackburn with Darwen	NHS England	1/1
n/a	Hannah Booth 2025-0615 · Susan Evans Fragmented IT systems and poor information sharing between and within services meant crucial mental health information about the mother was not readily …	East Midlands Derby and Derbyshire	Derbyshire Community Health Services NHS … Derbyshire Healthcare NHS Foundation Trust NHS Derby & Derbyshire Integrated … NHS England	5/5
n/a	Man Ng 2025-0614 · Richard Brittain Complex and non-streamlined processes for subarachnoid haemorrhage treatment, compounded by neurointerventionalists lacking admitting rights, create unclear overall clinical responsibility and risk patient …	West Midlands Coventry	[REDACTED] President of The Royal … [REDACTED], President of The Royal … [REDACTED] President of The Royal …	3/3
n/a	Syeda Fatima 2025-0613 · Adam Hodson Significant and systemic cultural tensions, including hierarchy and bullying, between midwifery and obstetric staff contributed to critical delays in patient care and …	West Midlands Birmingham and Solihull	University Hospitals Birmingham NHS Foundation …	1/1