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 2 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
6 May 2026	Peter Gurney 2026-0261 · Penelope Schofield The Ministry of Defence has been aware of a possible link between exposure to Nitrobenzene and other explosives and bladder cancer for …	South East West Sussex, Brighton and Hove	Secretary of State for Defence	1/1
2 May 2026	Somtera Bibi 2026-0260 · Nadia Persaud Despite a patient's identified risks including domestic abuse and threats, no relapse prevention or family safety plan was in place, and there …	London East London	East London Foundation NHS Trust	1/1
11 May 2026	Tung Tran 2026-0259 · Richard Brittain Concerns were raised about the lack of national guidance for monitoring and prescribing in hepatitis B reactivation prevention. There is also insufficient …	London Inner North London	British Association for the study … UK Health Security Agency	1/2
8 May 2026	Shay Middleton-Pierce 2026-0258 · Anna Loxton A British Transport Police dispatcher moved a priority log to a sub-queue due to human error, preventing timely action. There are no …	South East Surrey	British Transport Police	1/1
4 May 2026	Suseel Rana 2026-0257 · Emma Whitting The deceased's Clare's Law application was not progressed due to a misunderstanding, leading to a lack of multi-agency support and safety planning. …	East of England Bedfordshire and Luton	Bedfordshire Police Home Office	2/2
7 May 2026	Alan Whelan 2026-0256 · Oliver Longstaff A mandatory mental health assessment for a prisoner transferred to segregation was not completed within the required 24-hour timeframe, preceding the prisoner's …	Yorkshire and the Humber West Yorkshire East	Practice Plus Group Minstry of Justice	2/2
13 May 2026	Nigel Keenan 2026-0255 · Robert Cohen Concerns relate to weekday-only mental health support and low staffing at HMP Haverigg, which may incentivise prisoners in crisis to conceal their …	North West Cumbria	NHS England	1/1
30 Apr 2026	Poppy Lomas 2026-0253 · Andrew Walker Concerns are raised regarding a lack of clear risk consent forms and multidisciplinary meetings for unsafe home births, and that the term …	London North London	Department of Health and Social … National Institute for Health and … NHS England	3/3
4 Mar 2026	Rebekah Arter 2026-0252 · Andrew Harris There may have been missed opportunities for the IOPC and Metropolitan Police to identify the deceased as a victim of domestic abuse …	London South London	Home Office Independent Office for Police Complaints Metropolitan Police Service Secretary of State for Justice	3/4
8 May 2026	Jake Taylor 2026-0251 · Lydia Brown The coroner notes a lack of individual emergency planning for high-needs service users, inadequate staff training in CPR and defibrillator use, and …	London West London	Choice Support NHS England NHS South West London ICB	3/3
4 Jul 2023	Stella James 2026-0250 · Rachel Knight The coroner identifies a lack of a mechanism for services to be aware of an 'adult at risk' status and questions if …	Wales South Wales Central	Cardiff Citu Council	1/1
26 May 2023	Paige Allen 2026-0249 · Graeme Hughes The coroner notes that mental health practitioners in CTMUHB may lack immediate access to comprehensive medical records, such as WARRN assessments and …	Wales South Wales Central	Cwm Taf Health Board	1/1
6 May 2026	Sunny Eymond 2026-0246 · Simon Burge The report identifies a lack of national guidance for cross-Trust transfers of complex cases and a gap in specified national treatment pathways …	South East Hampshire, Portsmouth Southampton	NHS England	1/1
29 Apr 2026	Alice Dearden 2026-0231 · Nicholas Rheinberg The report notes that mail-order businesses may be unable to perform required suspicious transaction checks for reportable substances under the Poisons Act …	South West Wiltshire and Swindon	Ebay	1/1
29 Apr 2026	Alice Dearden 2026-0232 · Nicholas Rheinberg The coroner raises concerns that a former company's website mentions a method of self-destruction, references suicide websites, and includes a link to …	South West Wiltshire and Swindon	No addressees parsed	0/0
29 Apr 2026	Alice Dearden 2026-0233 · Nicholas Rheinberg The coroner raises concerns that strictly adhering to an 18th birthday cut-off for commissioning child and adolescent mental health provision could negatively …	South West Wiltshire and Swindon	NHS England	1/1
30 Apr 2026	Kenneth Cully 2026-0248 · Lorraine Harris The NHS Pathway system for ambulance call categorisation may not adequately assess uncontrolled bleeds due to insufficient questions, potentially leading to incorrect …	of East Riding of Yorkshire and …	No addressees parsed	1/0
1 May 2026	John McKinlay 2026-0243 · Emma Brown Mr McKinlay experienced multiple falls without appropriate observation according to his care plan, and there was no evidence of investigations into all …	West Midlands Birmingham and Solihull	University Hospitals of Birmingham NHS …	1/1
27 Apr 2026	Amy Chapman 2026-0247 · Nick Armstrong The Brighton Haven lacked clear policy and sufficient focus on authorising patient trips out, with concerns about nurses not reading notes, incomplete …	South East West Sussex, Brighton and Hove	1 Sussex Partnership NHS Foundation … 1 Sussex Partnership NHS Foundation …	1/2
30 Mar 2026	Moira Parker 2026-0239 · Bina Patel Staff lacked sufficient knowledge and training on when to make occupational health referrals, leading to a delay in a stress risk assessment …	East of England Bedfordshire and Luton	Unilver Plc	1/1