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 25 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
4 Sep 2025	Cheryl Edwards 2025-0449 · Geoffrey Sullivan The 60mph speed limit on the stretch of Sarratt Road between the M25 over-bridge and Sarratt Village is too high, posing a …	East of England Hertfordshire	Chief Executive Hertfordshire County Council	2/1
3 Sep 2025	Margaret Bailey 2025-0448 · Andrew Bridgman Care agencies lack a clear triage algorithm for non-medical call handlers and carers cannot perform basic observations, hindering effective client monitoring and …	North West Manchester South	Chief Executive, Care Quality Commission Secretary of State for Health …	2/2
3 Sep 2025	Marcia Grant 2025-0447 · Marilyn Whittle A shortage of foster placements, combined with inadequate documentation, poor communication of risks, and a failure to assess risks to carers, led …	Yorkshire and the Humber South Yorkshire (West)	Chief Executive, Rotherham Metropolitan Borough … Secretary of State for Education, …	2/2
25 Jun 2025	Muhammad Qasim 2025-0446 · Louise Hunt Conflicting interpretations of "spontaneous pursuit" guidance and inadequate police training pose risks. Furthermore, the IOPC's investigation priorities led to the absence of …	West Midlands Birmingham and Solihull	IOPC College of Policing	2/2
26 Aug 2025	Gabriella Jaiyesimi 2025-0444 · Mary Hassell Tesco staff, including duty managers, lacked basic first aid and CPR training, resulting in a failure to recognize cardiac arrest, perform life-saving …	London Inner North London	Chief Executive Security Industry Authority … Chief Executive Tesco PLC Chief Executive Total Security Services …	3/3
29 Aug 2025	Audrey Newman 2025-0443 · Andrew Bridgman A lack of trained ward doctors for lumbar punctures and the absence of a formal escalation pathway for assistance created significant delays …	North West Manchester South	CEO, Stockport NHS Foundation Trust	1/1
28 Aug 2025	Kore Padgett 2025-0441 · Charlotte Keighley There was a lack of staff training for hard collar fitting and poor communication between clinicians, leading to insufficient consideration of treatment …	Yorkshire and the Humber West Yorkshire West	Calderdale and Huddersfield NHS Foundation …	1/1
28 Aug 2025	Edwin Price 2025-0440 · Vanessa McKinlay A falls risk assessment was not completed within the required timeframe, failing to identify specific risks and implement mitigation measures, and no …	South West Somerset	Somerset NHS Foundation Trust	1/1
26 Aug 2025	Anne Dyson 2025-0439 · David Place Radiologists receive inconsistent and limited patient information, often focused to specific areas, risking confirmation bias and delayed diagnoses by restricting comprehensive scan …	North East Sunderland	South Tyneside and Sunderland NHS …	1/1
21 Aug 2025	Nicholas Murphy 2025-0437 · Robert Simpson Critical information regarding a patient's refusal of treatment may be missed due to inadequate outcome codes, leading to misleading impressions and hindering …	South East Hampshire, Portsmouth and Southampton	NHS England	1/1
20 Aug 2025	Mary Fitzpatrick 2025-0435 · Mary Hassell An unnecessary hospital admission and inadequate district nursing care for a pressure sore, compounded by a lack of organizational reflection, led to …	London Inner North London	Chief Executive Whittington Health NHS …	1/1
19 Aug 2025	Gemma Weeks 2025-0428 · Brendan Allen Public and young people lack understanding of ketamine's severe dangers, exacerbated by its Class B classification suggesting lower risk, leading to increased …	South West Dorset	Secretary of State for Education Secretary of State for Health … Secretary of State for the …	3/3
20 Aug 2025	Masood Hamid 2025-0434 · Joanne Kearsley There was a lack of planning for safe patient transport, particularly for a dementia patient, and an ineffective investigation into the death, …	North West Manchester North	Chief Constable Greater Manchester Police Chief Executive North West Ambulance … Chief Executive Oldham Borough Council Chief Executive Pennine Care NHS …	4/4
22 Aug 2025	Lee Stammers 2025-0438 · Louise Slater Poor documentation, communication, and system failures led to urgent medical tests being missed or inaccurately recorded. Unidentified temporary staff could also cancel …	Yorkshire and the Humber South Yorkshire East	Doncaster Royal Infirmary	1/1
1 Aug 2025	Sidi Bojang 2025-0436 · Andrew Walker Patients exhibiting recent self-harm or suicidal thoughts were discharged by a senior psychiatric nurse without a psychiatrist review, despite significant changes in …	London North London	Department of Health and Social …	1/1
20 Aug 2025	Ricky O’Connell 2025-0433 · Alison Mutch Ambulance response times are severely impacted by significant delays in clearing emergency departments and high demand for services, exacerbated by challenges in …	North West Manchester South	Department of Health and Social …	1/1
20 Aug 2025	Charles Stonley 2025-0432 · Anita Bhardwaj Limited resources and a severe shortage of mental health beds mean vulnerable patients in crisis are left in Emergency Departments for prolonged …	North West Liverpool and Wirral	Deputy Director of Patient Safety … Health Services Safety Investigations Body … National Director FOR Mental Health NHS England Improvement (PFDs)	2/4
18 Aug 2025	Emily Hewerdine 2025-0431 · Elizabeth Didcock Patients faced inadequate hydration assessments and fluid charting, nursing failures to identify deterioration, and a lack of clinical assessment in the Emergency …	East Midlands Nottingham and Nottinghamshire	Chief Executive, Doncaster and Bassetlaw …	1/1
12 Aug 2025	James Rownsley 2025-0430 · Nicola Mundy There is insufficient awareness and communication regarding the fire risks of emollient creams near heat, particularly for vulnerable individuals. Current reporting systems …	Yorkshire and the Humber South Yorkshire East	National Fire Chiefs Council	1/1
19 Sep 2025	Kwabena Amoateng 2025-0429 · Graeme Irvine A critically important paediatric respiratory action plan was mislabelled and misfiled in online records, preventing emergency healthcare professionals from accessing vital guidance …	London East London	South-East London Integrated Care System Chief Nursing Officer, NHS North-East … South East London ICB National Medical Director, NHS England	0/4