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 |
|---|---|---|
| 13 Oct 2025 |
Mark Townsend
2025-0512 · Tanyka Rawden
Stewards' lack of awareness regarding the nearest radio location caused delays in summoning medical assistance, posing a future risk for timely emergency …
|
1/1 |
| 13 Oct 2025 |
Jack Peatling
2025-0510 · Sean Horstead
A chronic lack of available in-patient mental health beds for high-risk patients who cannot be safely managed in the community led to …
|
2/2 |
| 13 Oct 2025 |
Abigail Jelley
2025-0509 · Nicholas Walker
Community Mental Health Teams lack mandatory perinatal red flag training and professional curiosity, exacerbated by cultural issues and structural leadership problems, risking …
|
1/1 |
| 13 Oct 2025 |
Jamie Funnell
2025-0508 · Rachel Redman
An expired alcohol dependence policy, chaotic emergency care with faulty equipment and incorrect CPR, and insufficient training evidence demonstrate a cavalier attitude …
|
1/1 |
| 10 Oct 2025 |
Jillian Steedman
2025-0506 · Sonia Hayes
Failures in information sharing, incomplete care plans, and inadequate risk assessments led to an inappropriate discharge placement that was not adequately monitored, …
|
2/2 |
| 9 Oct 2025 |
Leo Barber
2025-0505 · Edmund Gritt
Vulnerable children can access online suicide material, and international service providers’ jurisdictional stance can obstruct coronial investigations, hindering efforts to prevent future …
|
1/1 |
| 9 Oct 2025 |
Derek Crowther
2025-0500 · Chris Morris
Staff worked without mandatory life support training, and the lack of a digital system for contemporaneous patient observations hindered accurate monitoring and …
|
1/1 |
| 10 Oct 2025 |
Adrienne Studholme
2025-0504 · Christopher Long
Inaccurate fluid balance charting, unrecorded seizure activity, and a lack of procedures for ED readmission after recent surgery, including insufficient triage training, …
|
1/1 |
| 9 Oct 2025 |
Pauline Stirling
2025-0503 · Leila Benyounes
Inadequate documentation of positional changes, insufficient training for agency nurses, and a lack of wound care training despite safeguarding referrals contributed to …
|
1/2 |
| 7 Oct 2025 |
Ann Laskowsky
2025-0502 · Charlotte Keighley
Inadequate first aid training for police officers in assessing patient conditions and poor awareness of a dedicated medical advice line led to …
|
3/2 |
| 8 Oct 2025 |
Brian Ingram
2025-0501 · Andrew Cox
Inadequate staff introductions, family exclusion leading to incomplete patient history, poor inter-organisational information sharing, and incomplete patient assessments by triage staff resulted …
|
1/3 |
| 9 Oct 2025 |
Matthew Goldsmith
2025-0499 · Nadia Persaud
Multiple significant abnormal findings in abdominal CT scans were repeatedly missed by radiologists, aggravated by the absence of a required peer review …
|
1/1 |
| 8 Oct 2025 |
William King
2025-0496 · Sean Cummings
Failures in documenting consent, insufficient explanation of treatment risks, and a lack of clear professional responsibility meant essential medical policies were not …
|
3/4 |
| 8 Oct 2025 |
Richard Hunt
2025-0498 · Fiona Butler
Deliberate tampering with prison fire alarm systems, disabling their buzzers, led to undetected fires, a systemic issue worsened by the absence of …
|
1/3 |
| 17 Sep 2025 |
Martin Collins
2025-0497 · Peter Taheri
The prison telephone system lacks automated monitoring for unusual call volumes and there's no system for manual oversight, leading to missed opportunities …
|
1/1 |
| 7 Oct 2025 |
Amanda Wood
2025-0495 · Chris Morris
No sepsis screen was performed before discharge from the Emergency Department, indicating a failure in early identification and treatment of sepsis.
|
1/1 |
| 7 Oct 2025 |
Imogen Nunn Prevention of future deaths report
2025-0494 · Penelope Schofield
A national shortage and lack of regulation for British Sign Language interpreters, alongside procurement issues and few BSL-proficient clinicians, create significant risks …
|
1/4 |
| 2 Oct 2025 |
Beatrice Smith
2025-0493 · Robert Cohen
No effective internal investigation was conducted after the death, missing learning opportunities. Staff also received no additional training or guidance, risking a …
|
1/1 |
| 6 Oct 2025 |
Steven Turzynski
2025-0492 · Caroline Saunders
Inadequate communication between dietetic teams and insufficient monitoring of telephone-based nutritional assessments for cancer patients led to poor nutritional status and potentially …
|
2/2 |
| 2 Oct 2025 |
Georgia Barter
2025-0491 · Dr Shirley Radcliffe
Frontline police officers face difficulty accessing the Police National Database for domestic abuse history across different force areas, hindering proactive identification and …
|
1/1 |