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 |
|---|---|---|
| 1 Oct 2025 |
Milos Jankovic
2025-0490 · Rachel Knight
Inadequate follow-up for Barrett’s oesophagus in primary care, including a lack of routine recall and prompts for GPs to consider endoscopy, is …
|
1/3 |
| 29 Sep 2025 |
Mohammad Asghar
2025-0489 · Graeme Irvine
The Trust's governance failed to investigate a serious incident, despite multiple triggers and court orders, revealing a misunderstanding of patient safety guidelines …
|
1/1 |
| 29 Sep 2025 |
Jake Girton
2025-0488 · Graeme Irvine
Police failed to inform the hospital of a patient's release from custody, hindering mental health support efforts. The Metropolitan Police Service also …
|
1/1 |
| 24 Sep 2025 |
Steven Hart
2025-0487 · Sean Cummings
Systemic failings included an unmonitored ligature point in a 'safer cell,' inadequate communication of mental state risks during handovers, and observations not …
|
1/1 |
| 25 Sep 2025 |
Catherine Moore
2025-0486 · Daniel Sharpstone
The MOD's vehicle maintenance system (JAMES) is complex, lacks audit capabilities, and has no formal processes for inspecting, testing, or providing feedback …
|
0/1 |
| 25 Sep 2025 |
Pamela Honeybone
2025-0485 · Catherine Cundy
Persistent failures in patient identification processes, including staff not checking identity and delayed recognition of errors, continue to pose a significant risk …
|
1/1 |
| 26 Sep 2025 |
Richard Ellis
2025-0483 · Joanne Andrews
There are no legal requirements for the servicing and maintenance of agricultural tractors, leaving safety dependent solely on owner discretion and posing …
|
1/1 |
| 25 Sep 2025 |
Zara Cheesman
2025-0481 · Elizabeth Didcock
Emergency medical services lacked detailed understanding of child assessment issues, relied on incorrect physiological scoring, and had insufficient audit, monitoring, and professional …
|
1/1 |
| 24 Sep 2025 |
Honoria Culshaw (2)
2025-0480 · Anna Morris
A lack of information sharing regarding positive bacterial swab results from a pacemaker wound potentially delayed necessary extraction, contributing to prolonged infection.
|
1/1 |
| 24 Sep 2025 |
Honoria Culshaw (1)
2025-0479 · Anna Morris
Critical information regarding the need for pacemaker extraction was not adequately communicated between specialist and local hospitals, nor to the patient's GP, …
|
1/1 |
| 24 Sep 2025 |
Mark Smith
2025-0478 · Sean Horstead
The GP practice lacked a system or policy to ensure appropriate medication reviews for vulnerable patients with addiction or self-harm history, risking …
|
1/1 |
| 23 Sep 2025 |
Christopher Bird
2025-0477 · David Ridley
Concerns were raised about the reliability of the nhs.net email system for transmitting critical mental health information to GPs, leading to systemic …
|
2/3 |
| 18 Sep 2025 |
Leonardo Machado
2025-0476 · Brendan Allen
A lack of oversight regarding the 'rental' of food delivery licenses to children under 18 places them in vulnerable lone-working situations, increasing …
|
4/4 |
| 23 Sep 2025 |
Tony Jackson
2025-0475 · Graeme Irvine
A fatal iatrogenic injury went undetected due to extremely poor patient records, and the Trust's governance failed to identify the case for …
|
2/2 |
| 16 Sep 2025 |
John Franklin
2025-0474 · Sarah Murphy
A high-risk falls patient was discharged home before a careline pendant was confirmed as installed, with conflicting records on its provision, raising …
|
0/1 |
| 18 Sep 2025 |
Pamela Singh
2025-0473 · Gavin Knox
There is a lack of specific practice tools for family and care staff to recognise and escalate acute health deterioration in people …
|
1/1 |
| 17 Sep 2025 |
Keith Hankin
2025-0472 · Karen Henderson
A community urology service lacked robust clinical governance, integration with NHS services, and proper appraisal of clinicians, leading to fragmented care and …
|
5/5 |
| 16 Sep 2025 |
Christian Marsh Prevention of future deaths report
2025-0471 · Leila Benyounes
There is no formal system for communication, information sharing, and handover of patient data between a respite facility and the Intensive Support …
|
1/2 |
| 19 Sep 2025 |
Luke Chatterton
2025-0470 · Andrew Harris
Significant delays in accessing advanced life support in a mental health hospital and a lack of national guidelines for managing antipsychotic-induced bowel …
|
0/6 |
| 16 Sep 2025 |
Mohammed Khan
2025-0469 · Emma Brown
Paramedics lacked mandatory training and experience in obstetric emergencies, specifically breech deliveries, and national guidelines were not adhered to, leading to delayed …
|
3/8 |