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 |
|---|---|---|
| 10 Nov 2025 |
Jacqueline Aarons
2025-0576 · Andrew Walker
A lower hospital admission threshold for patients with learning disabilities is required. Furthermore, doctor's discharge instructions and safety netting advice for non-medical …
|
1/1 |
| 12 Nov 2025 |
Samuel Stewart
2025-0574Deceased · Lydia Brown
No action was taken by prison or healthcare after a prisoner tested positive for non-prescribed drugs on a "drug free" wing, missing …
|
2/3 |
| 11 Nov 2025 |
Liliane Bowden
2025-0570 · Henry Charles
Significant ambulance delays, caused by high demand and prolonged hospital handovers, led to extended waits for Category 3 calls. This poses a …
|
1/1 |
| 11 Nov 2025 |
Joan Talbot
2025-0569 · Liliane Field
Due to a lack of continuity across different admitting teams, the significance of a patient's repeated symptoms was not fully appreciated, delaying …
|
1/1 |
| 6 Nov 2025 |
Samuel Vass
2025-0568 · Guy Davies
The lack of speed enforcement on a specific A3083 road stretch has contributed to multiple fatal collisions caused by excessive speeding.
|
0/1 |
| 5 Nov 2025 |
Matthew Singh Prevention of future deaths report
2025-0567 · Kate Robertson
High availability and use of illicit psychoactive substances persist at HMP Berwyn, posing significant risks to prisoner health and contributing to future …
|
1/2 |
| 6 Nov 2025 |
Aaron Taylor
2025-0566 · Christopher Long
Prison staff failed to open an ACCT process after a self-harm incident and lacked ACCT training. Keyworker sessions for vulnerable prisoners were …
|
1/1 |
| 6 Nov 2025 |
Aaron Taylor
2025-0565 · Christopher Long
HMP Garth has a critical lack of psychologist resources for prisoners, with severe staffing gaps and extensive waiting lists for mental health …
|
1/1 |
| 7 Nov 2025 |
Richard Worswick
2025-0564 · Alison Mutch
Unclear wound care instructions on hospital discharge and a lack of documented communication between the hospital and care home led to confusion. …
|
2/2 |
| 6 Nov 2025 |
Judith Hughes
2025-0563 · Simon Milburn
The hospital's fall risk assessment tool is confusing due to unclear factor definitions, risking incorrect scores, insufficient observation levels, and increased patient …
|
1/1 |
| 3 Nov 2025 |
Kathleen Ward
2025-0562 · Lorraine Harris
The emergency department faces persistent overcrowding with patients awaiting ward beds, leading to delays in appropriate emergency care and risking repeat incidents …
|
1/1 |
| 4 Nov 2025 |
Maureen Christy
2025-0561 · Tim Holloway
There were critical shortcomings in disseminating and understanding policy changes, specifically for Covid contact testing, leading to clinician confusion and policies not …
|
1/1 |
| 5 Nov 2025 |
Vivian Nolan
2025-0560 · Paul Appleton
Clinicians lack sufficient knowledge and guidance on the increased risks associated with diagnostic colonoscopies for patients aged 80 and over.
|
1/1 |
| 5 Nov 2025 |
Jennifer Cahill and Agnes Cahill
2025-0559 · Joanne Kearsley
There is a critical absence of national guidance for home births, particularly for high-risk pregnancies, leading to inconsistent midwife practice, insufficient risk …
|
7/2 |
| 4 Nov 2025 |
Oliver Gorman
2025-0558 · Andrew Bridgman
There are inadequate age restrictions on dangerous aerosol products and unclear warnings about instant death. Social media platforms also fail to take …
|
4/4 |
| 3 Nov 2025 |
Brian Lloyd
2025-0557 · Andrew Walker
Patients with two failed catheter insertion attempts are not being transferred to hospital promptly, creating a risk of delay in necessary medical …
|
2/1 |
| 24 Oct 2025 |
Stephen Neville
2025-0556 · Sean Horstead
Nursing staff failed to properly conduct and record therapeutic observations due to misunderstanding and training deficits. The quality assurance and auditing processes …
|
1/1 |
| 31 Oct 2025 |
Gloria Simon (2)
2025-0555 · David Lewis
Miscommunication about the care home's status led a GP to not visit. Care home staff lacked training on obtaining urgent clinical input …
|
1/1 |
| 31 Oct 2025 |
Gloria Simon (1)
2025-0554 · David Lewis
A GP's misreading of oxygen saturation levels and incorrect assumption about the care facility's status led to inadequate assessment. The GP also …
|
1/1 |
| 31 Oct 2025 |
Gunaratnam Kannan
2025-0553 · Sarah Wood
There is a critical lack of joint policy and training among emergency and mental health services regarding Mental Capacity Act and Mental …
|
3/3 |