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 |
|---|---|---|
| 19 Aug 2025 |
Venetia Pierce
2025-0427 · Susan Ridge
An EMIS system failed to flag a nitrofurantoin safety alert because it only triggered for pre-existing conditions, alongside generally low clinician awareness …
|
1/2 |
| 6 Aug 2025 |
Jacob Wooderson
2025-0426 · Sarah Bourke
Concerns exist about the fatal cardiac side effects of Elvanse, especially with remote prescribing relying on potentially unreliable patient-reported observations and verbal …
|
2/2 |
| 11 Aug 2025 |
Quy Thi Pham
2025-0425 · Sonia Hayes
Strict adherence to national cervical screening guidance led to delayed smear tests for a vulnerable patient, with the guidance potentially excluding a …
|
2/3 |
| 12 Aug 2025 |
Resmije Ahmetaj
2025-0424 · Sonia Hayes
Mental health services exhibited inadequate clozapine monitoring, poor communication and escalation regarding subtherapeutic medication levels, and delayed management of critical side effects, …
|
2/2 |
| 12 Aug 2025 |
Robert Simpson
2025-0423 · Ana Samuel
A patient was discharged with incorrect medication and missed critical antibiotic doses due to stock issues and poor communication, highlighting systemic failures …
|
1/1 |
| 12 Aug 2025 |
Charlotte Noordam
2025-0422 · Ana Samuel
A high-incident crossroads junction is inherently confusing due to its non-signalised, historic design, posing an ongoing safety risk despite current legal compliance.
|
1/1 |
| 12 Aug 2025 |
Chloe Barber
2025-0421 · Paul Marks
Critical gaps exist in transitional care pathways from CAMHS to adult services, along with unclear guidelines for administering antipsychotic depots and a …
|
2/3 |
| 12 Aug 2025 |
Margaret Taylor
2025-0420 · Rebecca Ollivere
A patient was removed from a soft food diet without proper assessment or documentation, and external food was not checked for suitability …
|
1/1 |
| 15 Dec 2023 |
Peter Kelly
2025-0419 · Nicola Mundy
Custody sergeants lacked understanding of Liaison and Diversion team processes, available information, and how to complete pre-release risk assessments. This indicates a …
|
1/1 |
| 7 Aug 2025 |
Victor Hutchens
2025-0418 · Rebecca Sutton
Care rounds were erroneously reduced from hourly to four-hourly, and the staff member responsible couldn't explain how the error occurred, raising concerns …
|
1/1 |
| 8 Aug 2025 |
Gareth Jackson
2025-0417 · Paul Rogers
Inadequate handover and record-keeping on a psychiatric ward led to a high-risk suicidal patient being permitted unescorted leave, contrary to the safety …
|
1/1 |
| 7 Aug 2025 |
Tracey Ostler
2025-0416 · Caroline Topping
A severe shortage of psychiatric beds results in acute mental health patients being unlawfully and inappropriately detained in emergency departments for extended …
|
8/7 |
| 8 Aug 2025 |
Jessica Smithson
2025-0415 · Joanne Kearsley
The delayed rollout of national 24/7 crisis text services leaves a critical gap, with charities filling the void inconsistently, leading to varied …
|
3/3 |
| 7 Aug 2025 |
Kenneth Edwards
2025-0414 · Benjamin Myers
A subdural haematoma was missed by an out-of-hours CT scan reporting service, leading to delayed treatment and the inappropriate administration of blood-thinning …
|
1/1 |
| 7 Aug 2025 |
Marion Jones
2025-0413 · Benjamin Myers
A care home failed to assess and implement bed rails for an unstable patient, despite family concerns, and also neglected to use …
|
1/1 |
| 21 Jul 2025 |
Jean Dye
2025-0412 · Paul Smith
An unexplained Emergency Power Off (EPO) circuit activation caused a critical power loss during an emergency procedure, with no in-lab indicators or …
|
2/2 |
| 6 Aug 2025 |
Stephen Lawrence
2025-0411 · Anna Crawford
A resident sustained unexplained injuries, followed by deficient record-keeping, delayed medical advice after a fall, and conflicting evidence from the nursing home …
|
1/1 |
| 4 Aug 2025 |
John Bell
2025-0410 · Simon Tait
Critical renal findings were not communicated to spinal surgeons, resulting in spinal surgery being inappropriately performed before a necessary renal procedure. Subsequently, …
|
1/1 |
| 5 Aug 2025 |
Daisy McCoy
2025-0409 · Deborah Stewart
Critical delays in performing a Caesarean section were caused by significant communication failures among staff, inadequate training on recognising abnormal foetal movements, …
|
1/1 |
| 18 Jun 2025 |
Kathleen Gregory
2025-0408 · Darren Stewart
A paramedic misinterpreted a ReSPECT form, believing it precluded resuscitation for choking, which may be a reversible event, raising concerns about form …
|
1/1 |