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 |
|---|---|---|
| 24 Oct 2025 |
Caitlin Imber
2025-0538 · John Gittins
CAMHS closed a referral for a vulnerable child due to missing contact information without making further enquiries, causing a significant and potentially …
|
1/1 |
| 17 Oct 2025 |
Melanie Walker
2025-0529 · Timothy Brennand
Heart monitors have a critical design flaw where disconnected leads do not continuously re-alarm after initial acknowledgement, risking unobserved and fatal cardiac …
|
3/3 |
| 24 Oct 2025 |
Sophie Towle
2025-0552 · Alexandra Poutney
There was a critical lack of joint policy and liaison between physical and mental health teams for complex cases involving foreign body …
|
2/3 |
| 28 Oct 2025 |
Patricia Genders
2025-0551 · Nick Armstrong
Over-reliance on A&E for mental health crises due to inadequate dedicated placements creates an unsuitable and insecure environment, risking patient deterioration and …
|
2/2 |
| 11 Aug 2025 |
Paul Pidgeon
2025-0550 · Anna Crawford
A wholesale supplier failed to verify a customer's authorization to distribute medicinal products, leading to bulk sales of paracetamol and ibuprofen to …
|
1/1 |
| 29 Oct 2025 |
Evan Dandou-Dambelle
2025-0549 · Mary Hassell
Significant changes in a mental health patient's medication are not automatically factored into decisions about their required level of contact and observation.
|
1/1 |
| 19 Oct 2025 |
Alexander McCormack
2025-0548 · Sophie Lomas
Inefficient transfer of missing persons cases between police forces due to inadequate training for transferees on data import procedures, risking delays in …
|
1/1 |
| 28 Oct 2025 |
Lewis Garfield
2025-0547 · Hassan Shah
Ambulance service communications were inadequate, leading to delayed clinician review and escalation. Lengthy hospital handover delays severely impact ambulance availability and emergency …
|
4/4 |
| 28 Oct 2025 |
Raymond Leake
2025-0546 · Lorraine Harris
An urgent radiology scan was missed, likely due to human error, and new preventative processes lack auditing due to staff shortages, leaving …
|
1/1 |
| 28 Oct 2025 |
Alan Horrocks
2025-0545 · Peter Merchant
Patient observations were not completed per escalation guidance, delaying deterioration recognition. Increased ward capacity without corresponding nursing staff and existing staffing gaps …
|
1/1 |
| 27 Oct 2025 |
Louisa Walker (2)
2025-0544 · Heidi Connor
A significant majority of obstetricians have not received crucial specific training related to this incident, raising concerns about the trust's commitment to …
|
1/1 |
| 27 Oct 2025 |
Louisa Walker (1)
2025-0543 · Heidi Connor
There is a lack of national guidance and relevant training for the increasingly common obstetric emergency of impacted fetal head during caesarean …
|
2/1 |
| 27 Oct 2025 |
Danielle Jones
2025-0542 · Joanne Lees
The GP repeatedly prescribed large amounts of medication, including substances used in overdose, without adequate review, despite the patient self-reporting multiple overdoses …
|
1/1 |
| 20 Oct 2025 |
Declan Carr
2025-0541 · Sarah Middleton
Inadequate national policy for sharing information on psycho-social support for substance misuse during prisoner transfers risks continuity of care and future deaths.
|
1/1 |
| 23 Oct 2025 |
Saranveer Sihota
2025-0540 · Peter Nieto
The building's low top-floor wall presents a clear and known risk of fatal falls, especially for individuals with suicidal thoughts, with multiple …
|
1/1 |
| 24 Oct 2025 |
Alexander Lewis
2025-0539 · Aled Gruffydd
Pursuing drivers lacked the ability to communicate dynamic risk assessments, were overburdened with tasks leading to missed critical information, and police training …
|
3/2 |
| 23 Oct 2025 |
Mark Foster
2025-0537 · Kirsty Gomersal
The practice suffers from a lack of unified leadership, poor governance, and an inadequate system for investigating incidents.
|
1/1 |
| 21 Oct 2025 |
Steven Davidson
2025-0536 · Stephen Simblet
Healthcare staff at HMP Chelmsford lack proficiency in navigating System One records to find critical past self-harm information, or are unaware of …
|
1/1 |
| 23 Oct 2025 |
Ann Campbell
2025-0535 · Andrew Cox
The steps are unsafe as the handrail is too low and short, preventing individuals from adequately steadying themselves when descending.
|
1/1 |
| 18 Jun 2025 |
Pamela Brand
2025-0534 · Darren Stewart
Hospital records lacked key details regarding patient observations and clinical decision-making rationale, posing a risk to the quality of future patient care.
|
1/1 |