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 21 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
22 Oct 2025	Ricky Monahan 2025-0533 · Louise Hunt An unprotected fire escape allowed easy roof access from a rehabilitation unit due to inadequate railings, without an environmental risk assessment. There …	West Midlands Birmingham and Solihull	Birmingham and Solihull Integrated Care … Care Quality Commission NHS England	3/3
17 Oct 2025	Owen Donnelly 2025-0532 · Timothy Brennand Easy online access to information for constructing weapons, currently not illegal to possess, creates a real risk due to the proliferation of …	North West Manchester West	Department of Health and Social … Home Department	1/2
22 Oct 2025	Amy Cross 2025-0531 · Peter Harrowing There is no system to ensure vital healthcare information, including medication and observations, is shared between criminal justice healthcare providers, and no …	South West Avon	IPRS Aeromed Mitie NHS England Practice Plus Group	1/4
21 Oct 2025	Paul Appleby 2025-0530 · Anne Pember The absence of a regular Saturday Court Service by the Liaison and Diversion Team, relying solely on an 'On Call' system, raises …	East Midlands Northamptonshire	Northamptonshire Healthcare Foundation Trust	1/1
21 Oct 2025	Amber Walker 2025-0528 · Brendan Allen Doctors are reluctant or presume others have discussed SUDEP with epilepsy patients, despite its critical importance. There's a lack of universal use …	South West Dorset	Department of Health and Social …	1/1
20 Oct 2025	Stuart Fowkes 2025-0527 · Joanne Lees Devon and Cornwall Police failed to share vital information regarding the deceased's suicidal intent with West Midlands Police, leading to critical risk …	West Midlands The Black Country	Devon & Cornwall Police	1/1
10 Oct 2025	William Puplett 2025-0526 · Andrew Walker Emergency dispatch protocols lack specific questions for tracheostomy patients regarding suction equipment availability and use, risking delayed high-priority responses for breathing difficulties.	London North London	International Academies of Emergency Dispatch	1/1
20 Oct 2025	Marc Davies 2025-0525 · Caroline Saunders Inadequate welfare checks by security guards, stemming from a lack of training on proper procedures and documentation, risked residents not receiving timely …	Wales Gwent	MJ Events Monmouthshire County Council	1/2
20 Oct 2025	John Rust 2025-0524 · Adam Hodson Mandatory training for automated CSF drainage systems is not adequately enforced, with many staff untrained. There's no sustainable plan to ensure all …	West Midlands Birmingham and Solihull	University Hospitals Birmingham NHS Foundation …	1/1
16 Oct 2025	Martin Evans, Patricia Evans and Neil Errington 2025-0523 · Robert Cohen The DVLA's over-reliance on drivers self-reporting medical unfitness is problematic, as some individuals with impairments may lack insight or be unwilling to …	North West Cumbria	Department for Transport	2/1
29 Sep 2025	Naomi Aylott 2025-0522 · Robert Simpson The patient received no face-to-face care due to geographical distance, and the CMHT had inadequate risk assessment training, auditing, and family involvement …	South East Hampshire, Portsmouth and Southampton	Hampshire and Isle of Wight …	1/1
16 Oct 2025	Theo Treharne-Jones 2025-0521 · Gavin Knox The hotel room lacked secondary security for its easily disengaged door locks, and the pool had no physical barrier, allowing unsupervised access …	Wales South Wales Central	Association of British Travel Agents TUI UK	2/2
11 Oct 2025	Sarah Healey 2025-0520 · Joseph Turner Inadequate information sharing and a lack of a joined-up approach across health services for mental health patients with physical issues led to …	South East West Sussex, Brighton and Hove	Department of Health and Social …	1/1
15 Oct 2025	Malik Bunton 2025-0519 · Catherine Cundy Inadequate inquiry into a previous incident, flawed clinical review processes, and deliberate obstructions to evidence gathering impeded the RAF's ability to assess …	Yorkshire and the Humber North Yorkshire and York	Ministry of Defence	1/1
14 Oct 2025	William Roath 2025-0518 · David Reid A doctor's failure to advise "Nil by Mouth" and delay a SALT referral led to continued oral feeding, worsening aspiration pneumonia. Specific …	West Midlands Worcestershire	University Hospitals Birmingham NHS Foundation …	1/1
15 Oct 2025	Katie Overd 2025-0517 · Joanne Kearsley A lack of proactive public communication about the "Right Care Right Person" policy risks the public delaying seeking emergency assistance, misunderstanding response …	North West Manchester North	College of Policing RCRP Strategic Partnership Board	3/2
15 Oct 2025	Tony Duncan 2025-0516 · Alison Hewitt A psychiatric liaison team failed to conduct a proper risk assessment, overlooking suicidal ideation and acute mental health deterioration, leading to inappropriate …	London City of London	South London and Maudsley NHS …	1/1
14 Oct 2025	Thompson Elliott 2025-0515 · David Place Absence of clear policy for medication administration when hospital discharge letters are missing caused staff confusion, resulting in an opioid overdose and …	North East Sunderland	Care UK	1/1
14 Oct 2025	David Jones 2025-0514 · Nathanael Hartley The Emergency Department failed to review an undiagnosed aortic dissection, and a middle-grade doctor did not escalate a changing clinical picture, indicating …	East Midlands Nottingham and Nottinghamshire	Nottingham University Hospitals NHS Trust	1/1
14 Oct 2025	Mohan Hothi 2025-0513 · Graeme Irvine The Trust failed to investigate two serious unwitnessed falls, hindering its ability to identify and remediate suboptimal practices, with vague evidence of …	London East London	Barking, Havering and Redbridge University …	1/1