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 |
|---|---|---|
| 15 Sep 2025 |
Linda Sharp
2025-0468 · Paul Marks
Relying solely on a low Wells score is a fundamentally flawed approach to exclude deep vein thrombosis or pulmonary embolus, potentially leading …
|
2/1 |
| 8 Jul 2025 |
Peter Ramsden
2025-0467 · Paul Marks
A legal lacuna prevents police, paramedics, or fire services from forcing entry for welfare checks if a medical problem is suspected, hindering …
|
2/2 |
| 14 Sep 2025 |
Charlotte Tetley
2025-0466 · Sarah Murphy
A patient was prematurely removed from the inpatient bed list before an appropriate daily mental health review, despite documented need for admission, …
|
1/1 |
| 14 Sep 2025 |
Charlotte Tetley
2025-0465 · Sarah Murphy
A narrow police policy interpretation requires explicit intent to end life for high-risk missing person response, while ambulance services decline calls if …
|
1/1 |
| 12 Sep 2025 |
Gareth Johnson
2025-0464 · Kerrie Burge
Deteriorating hospital infrastructure and critical care capacity issues pose a significant risk, as safeguards against moving critically ill patients may fail under …
|
2/2 |
| 11 Sep 2025 |
Michael Moore
2025-0463 · Samantha Goward
Persistent NHS capacity constraints are causing significant and increasing delays in cancer referrals, diagnosis, and treatment, risking patient outcomes.
|
1/1 |
| 10 Sep 2025 |
Walter Horton
2025-0462 · Nicola Mundy
Concerns include poor record keeping for falls, wound management, and handover, alongside a failure to follow aseptic techniques for wound care, increasing …
|
1/1 |
| 10 Sep 2025 |
Keith Reynolds
2025-0461 · Thomas Crookes
Mechanical thrombectomy services are unavailable outside 9 am-5 pm due to insufficient neuroradiologists, posing a risk of preventable deaths for patients requiring …
|
1/1 |
| 10 Sep 2025 |
Stuart Gilchrist
2025-0460 · Lorraine Harris
Restaurants and food establishments are largely unaware of useful anti-choking devices, and there is no clear responsibility for advising them to stock …
|
2/3 |
| 9 Sep 2025 |
Brian Burrows
2025-0459 · Naomi McLoughlin
Prison officers lack training and guidance on decision-making when faced with competing emergency tasks like multiple cell bells and ACCT checks, risking …
|
1/1 |
| 8 Sep 2025 |
Mabel Williams
2025-0458 · Robert Sowersby
The Trust's patient information on birth after caesarean failed to explain uterine rupture risks, hindering informed consent, and changes following serious incidents …
|
1/1 |
| 8 Sep 2025 |
Mabel Williams
2025-0457 · Robert Sowersby
The RCOG information leaflet on birth options after a previous caesarean section fails to mention that uterine rupture can be fatal for …
|
1/1 |
| 8 Sep 2025 |
Maureen Gilbert
2025-0456 · Matthew Kewley
Identified flood defence measures for Tapton Terrace were not implemented due to cost, leaving the area vulnerable to flooding and posing a …
|
3/3 |
| 5 Sep 2025 |
Victoria Taylor
2025-0455 · Catherine Cundy
Secondary mental health services failed to offer appropriate trauma-informed treatment pathways or initiate a multi-agency approach for a patient with acknowledged childhood …
|
0/1 |
| 5 Sep 2025 |
James Cochrane
2025-0454 · Rebecca Connell
There is no clear guidance for mental health staff on using alternative evidence formats like video footage or on ensuring carers are …
|
1/1 |
| 4 Sep 2025 |
Nicola Mulliss
2025-0453 · Thomas Crookes
A lack of policy for microbiological swabbing during wound re-suturing meant a Staphylococcus Aureus infection was not detected early, delaying crucial treatment.
|
1/1 |
| 4 Sep 2025 |
Khalif Mohammed
2025-0452 · Louise Hunt
West Midlands Police experienced significant delays in allocating officers to a priority case due to insufficient resources, posing a risk of future …
|
1/1 |
| 3 Sep 2025 |
Peter Thomas
2025-0450 · Rachel Knight
The CIWA protocol is too blunt and lacks nuance for elderly or delirious patients, leading to risks of over-sedation due to clinicians …
|
1/1 |
| 30 Jun 2025 |
Ella David-Fong
2025-0442 · Lydia Brown
Inadequate guidance exists for families and carers on how to share concerns or communicate information when a patient, having capacity, withdraws consent …
|
2/1 |
| 2 Sep 2025 |
Edward Funnell
2025-0445 · Andrew Morse
Nursing staff demonstrated a lack of knowledge regarding podiatry referrals for pressure wounds and failed to follow a Tissue Viability Nurse's dressing …
|
1/1 |