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 |
|---|---|---|
| 5 Dec 2025 |
Leonardo Machado
2025-0611 · Brendan Allen
Insufficient oversight of 'rental' food delivery licenses to underage individuals places children in vulnerable lone working situations, increasing their risk of road …
|
1/5 |
| 8 Dec 2025 |
Oliver Mulangala
2025-0610 · Jonathan Stevens
The pervasive availability of illicit drugs, particularly new psychoactive substances, and mobile phones in HMP High Down leads to widespread misuse, coercion, …
|
1/4 |
| 5 Dec 2025 |
Alan Peet
2025-0609 · Alison Mutch
A nurse untrained in tracheostomy management was allocated to a unit with high-needs patients, and an agency nurse lacked system login rights, …
|
0/2 |
| 4 Dec 2025 |
Antonio Galisi-Swallow
2025-0608 · Oliver Longstaff
There is an absence of national guidance for the use of propofol for short-term sedation in children and young people in paediatric …
|
1/3 |
| 4 Dec 2025 |
Lina Piroli
2025-0607 · Melanie Lee
Elderly and complex patients, especially those with dementia, suffer detrimental delays in overcrowded A&E departments unequipped to provide specialist care, due to …
|
2/2 |
| 4 Dec 2025 |
Samuel Brown
2025-0606 · Abigail Combes
The primary care prescribing regime failed to identify potential addiction and drug-seeking behaviour, and neglected to review medications for ongoing necessity.
|
1/1 |
| 1 Dec 2025 |
John Hickmott
2025-0605 · Adam Smith
Numerous streetlights on a dangerous stretch of road were reported faulty but not repaired in a timely manner, severely reducing pedestrian visibility …
|
1/1 |
| 1 Dec 2025 |
Abdullah Ali
2025-0604 · Melanie Lee
Extensive and thick black mould in the property managed by Granddwell Estates poses a significant risk of future deaths.
|
1/1 |
| 25 Nov 2025 |
Connor Nelson
2025-0603 · Elizabeth Didcock
Emergency staff showed no improved ability to respond to cardiac arrest. Medical staff lacked understanding of prolonged QTc syndrome and a robust …
|
1/1 |
| 1 Dec 2025 |
Lewis Bates
2025-0602 · Chris Morris
Lack of guidance for 999 call handlers on 'reasonable enquiries' for missing persons and confusion with the 'Right Care Right Person' initiative …
|
1/1 |
| 27 Nov 2025 |
June Findlay
2025-0601 · Robert Simpson
Inadequate recognition, care planning, and monitoring of malnutrition risks by ward staff, who also failed to follow dietician advice. Auditing processes did …
|
1/1 |
| 26 Nov 2025 |
Evie Muir
2025-0600 · Stephen Simblet
Hospital reviews of unusual cardiac deaths are not sufficiently shared across specialties, and patients with cardiac and rheumatological conditions are inadequately assessed …
|
1/1 |
| 25 Nov 2025 |
Andrew McCleary
2025-0599 · Emma Whitting
Police officers lacked knowledge of Mental Capacity Act requirements for restraint, awareness of restraint risks, and failed to collaborate with ambulance staff …
|
1/1 |
| 26 Nov 2025 |
Celia Phillips
2025-0598 · Ana Samuel
Carers for a bed-bound patient lacked understanding and training in preventing pressure sores, failing to perform crucial repositioning or properly assess skin, …
|
1/1 |
| 26 Nov 2025 |
Evelyn Rae Le Masurier-O’Sullivan
2025-0597 · Sian Reeves
Midwifery staff failed to elicit and act upon parental concerns about a baby's breathing and crying during postnatal contacts, leading to missed …
|
1/2 |
| 10 Sep 2025 |
Air India Boeing 787
2025-0575 · Fiona Wilcox
Mortuaries demonstrate an under-appreciation of formalin dangers, lacking routine monitoring and appropriate equipment for handling highly contaminated repatriated bodies, exposing staff to …
|
1/2 |
| 1 Sep 2025 |
[REDACTED]
2025-0507 · Ian Potter
There were widespread failures in the quality, accuracy, and auditing of patient observations, including staff distraction during crucial monitoring. Concerns also persist …
|
1/1 |
| 25 Nov 2025 |
Benedict Blythe
2025-0595 · Elizabeth Gray
Pathology protocols for suspected anaphylaxis need revision to ensure appropriate sample collection and retention. Police investigations of unexplained child deaths also lack …
|
2/2 |
| 26 Nov 2025 |
Aminata Coulibaly
2025-0596 · Sonia Hayes
Police failed to share critical self-harm information with mental health services and contact handlers inadequately recorded severe welfare concerns, hindering appropriate assessment …
|
1/1 |
| 24 Nov 2025 |
Diana Grant
2025-0594 · Richard Travers
Critically ill mental health patients needing secure admission, especially if dangerous, face unavoidable prolonged detention in prison due to restricted unit capacity, …
|
2/2 |