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 |
|---|---|---|
| 18 Nov 2025 |
Jack Brown
2025-0593 · Sophie Lomas
Unregulated care agencies provide staff to care homes without oversight of recruitment or training, risking vulnerable residents being cared for by unsuitable …
|
1/1 |
| 20 Nov 2025 |
Lisa Bowen
2025-0592 · Richard Travers
A vehicle's anti-locking braking system (ABS) critically failed after a tyre detachment, incorrectly reducing braking and creating an unaddressed design flaw. This …
|
2/6 |
| 18 Nov 2025 |
Steven Ruddick
2025-0591 · Crispin Oliver
Procedural differences in observing detained persons during toilet visits between police and GeoAmey custody created an opportunity for prohibited items to be …
|
1/2 |
| 29 Sep 2025 |
Susan Barrett
2025-0590 · Sean Horstead
Serious concerns exist regarding the absence of embedded Tissue Viability Nurses and a Tissue Viability Service in community hospitals, leading to inadequate …
|
1/1 |
| 18 Nov 2025 |
Lynsey Dearden
2025-0589 · Emma Serrano
A patient allocated community mental health support received no appointments for months. Critically, there was no policy or framework guiding the timing …
|
2/2 |
| 18 Nov 2025 |
Dominic Hurley
2025-0588 · Penelope Schofield
The system for renewing diving licenses relies too heavily on self-declaration, failing to verify previous medical history or diving incidents, which risks …
|
1/2 |
| 17 Nov 2025 |
Andrew Dodds
2025-0587 · Marilyn Whittle
Police failed to provide next of kin details to the s136 suite and crucial information about prior s136 detention was missing from …
|
1/1 |
| 18 Nov 2025 |
Derrion Adams
2025-0586 · Emma Brown
Contraband and novel psychoactive substances continue to enter the prison, posing a risk to life and burdening staff during unpredictable "spikes" in …
|
1/1 |
| 17 Nov 2025 |
Paolino Amico
2025-0585 · Sonia Hayes
Multiple serious medication errors, including non-administration of pain relief and prescription mistakes, occurred. There were also critical failures in the discharge plan …
|
2/2 |
| 17 Nov 2025 |
Ethel Robertson
2025-0584 · Nicholas Walker
A critical communication gap exists as the Older People’s Mental Health Service is not routinely informed of their patients' ED admissions for …
|
1/1 |
| 17 Nov 2025 |
Thomas Morrell
2025-0583 · Thomas Crookes
Failure to promptly recognise heart failure and the absence of a HOCM patient referral SOP delayed specialist transfer. A lack of regular …
|
1/1 |
| 14 Nov 2025 |
Suzanne Ellerby
2025-0582 · Anna Loxton
A lack of universal safety netting guidelines for transferring vulnerable mental health patients from secondary to primary care leaves patients unsupported, leading …
|
2/2 |
| 14 Nov 2025 |
Margaret Crooks
2025-0581 · Alison Mutch
Confusion among stroke clinicians about the level of overnight expert support available led to delays in time-critical advice for stroke complications, potentially …
|
1/1 |
| 14 Nov 2025 |
Ronald Perry
2025-0580 · Alison Mutch
Poor documentation, incomplete falls risk assessments, and staff misunderstanding of the falls policy for anticoagulated patients led to inadequate care and missed …
|
1/1 |
| 12 Nov 2025 |
Barry Loxston
2025-0573Deceased · Fiona Wilcox
Serious failures pre-surgery included not recognising unfitness for transplant. Post-operatively, critically low potassium was untreated due to workload, and nursing care lacked …
|
1/1 |
| 12 Nov 2025 |
Christopher Sampson
2025-0572 · Adam Hodson
Drivers are failing to self-notify the DVLA of medical conditions, and there's a lack of clarity on medical professionals' awareness or effective …
|
3/4 |
| 11 Oct 2025 |
Joanna Chamberlain
2025-0571 · Joseph Turner
A gap exists in safe spaces for mental health patients needing more support than home teams provide. National guidance is needed for …
|
1/1 |
| 7 Nov 2025 |
Ernest Gray
2025-0579 · Patricia Harding
The hospital failed to involve the patient's primary carer in discharge planning and neglected to provide holistic information about his fluctuating delirium, …
|
1/1 |
| 11 Nov 2025 |
Tracey Oldfield
2025-0578 · Andrew Cox
Delayed prescription of usual medications for late-admitted patients leads to inappropriate alternative pain relief. The process for timely medication prescription for such …
|
1/1 |
| 10 Nov 2025 |
Alan Mitchell
2025-0577 · Alexander Frodsham
A patient's lifelong repeat prescription was removed by software without GP notification or patient choice, creating a risk that essential medication may …
|
1/1 |