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 |
|---|---|---|
| 5 Aug 2025 |
Mohsin Janjua
2025-0407 · M D Fleming
The unregulated online sale of substandard lithium-ion batteries for e-bikes poses a significant fire risk, with online marketplaces currently disclaiming safety responsibility. …
|
1/1 |
| 5 Aug 2025 |
Maureen Batchelor
2025-0406 · Joanne Andrews
The Emergency Department consistently treats patients in corridors due to severe overcrowding and insufficient clinical space, despite ongoing efforts, posing an unacceptable …
|
2/3 |
| 6 Aug 2024 |
Alfred Sparrow
2025-0405 · David Reid
Staff at The Meadows Nursing Home did not always assist Mr. Sparrow with his food and fluid intake as required by his …
|
1/1 |
| 5 Aug 2025 |
Simon Moore
2025-0404 · Richard Middleton
A lack of communication protocol meant critical welfare information from a distressed train driver was not relayed from the signaller to the …
|
1/1 |
| 11 Jul 2023 |
June Peel
2025-0403 · Alexandra Pountney
Failures in documenting injuries, inadequate handover of critical information, and staff not following care plans led to a patient with a femur …
|
1/1 |
| 2 Aug 2023 |
Lee Dryden
2025-0402 · Abigail Combes
NHS Trusts lack understanding of guidance for external image reporting, and the ambulance service experienced significant delays in responding to a category …
|
2/2 |
| 10 May 2023 |
Mojeri Adeleye
2025-0401 · Abigail Combes
There was a lack of regard for the mother's pregnancy knowledge and insufficient discussion with parents about potential measures for premature labour …
|
1/1 |
| 16 May 2023 |
Mark Ravensdale
2025-0400 · Abigail Combes
Mental health services failed to directly engage with the deceased to properly and adequately assess his mental health condition.
|
1/1 |
| 1 Aug 2025 |
Brian Ringrose
2025-0399 · Sean Cummings
Police officers failed to follow critical restraint training, including prolonged prone positioning and inadequate welfare monitoring. Officers also did not apply the …
|
3/3 |
| 1 Aug 2025 |
Margaret Medlicott
2025-0398 · David Reid
A care home admitted a resident with a history of aggression against policy, without proper clinical assessment. Staff lacked empowerment to challenge …
|
1/1 |
| 1 Aug 2025 |
Margaret McNaughton
2025-0397 · Joanne Lees
The Trust consistently fails to ensure adequate checking and documentation of patient allergy status, leading to ongoing adverse incidents, as current policies …
|
1/1 |
| 1 Aug 2025 |
Suzanne Edwards
2025-0396 · Tom Osborne
Emergency Departments lack reliable access to patients' primary care records, leading to delayed or misdirected diagnoses and undermining patient safety due to …
|
3/4 |
| 1 Aug 2025 |
Benjamin Buckfield
2025-0395 · Nicholas Walker
An unchecked, open trade in illegal drugs at the festival, combined with a policy that does not eject non-dealing possessors, creates a …
|
0/2 |
| 31 Jul 2025 |
Lewis Petryszyn
2025-0394 · Patricia Morgan
Policies lack specified timeframes for intervention and support for prisoners at risk of substance misuse, leading to delayed care and intervention from …
|
1/2 |
| 30 Jul 2025 |
Joanne Stones
2025-0393 · Gillian Kane
The hospital failed to prioritise a seriously ill patient, overlooking critical medical alerts and existing diagnoses, and neglected to consult specialists, leading …
|
1/1 |
| 12 Jun 2025 |
Oscar Keenan
2025-0392 · Judith Leach
Inadequate algorithms for assessing ill newborns/infants, particularly for respiratory problems, and over-reliance on these tools lead to delays in obtaining early clinical …
|
4/2 |
| 29 Jul 2025 |
Azroy Dawes-Clarke
2025-0391 · Ian Brownhill
The anti-ligature bedding failed, allowing ligature creation. Prison officers had inconsistent training on ACCT processes, first aid, and the Mental Capacity Act, …
|
1/1 |
| 29 Jul 2025 |
Joan Whitworth
2025-0390 · Andrew Hetherington
There were inadequate Speech and Language Therapy assessments, significant gaps in staff training for Basic Life Support, first aid, and nutritional assessments, …
|
2/2 |
| 29 Jul 2025 |
Azroy Dawes-Clarke
2025-0389 · Ian Brownhill
There was a significant lack of inter-agency dialogue and learning following a severe incident, leading to persistent confusion regarding command primacy and …
|
3/3 |
| 29 Jul 2025 |
Azroy Dawes-Clarke
2025-0388 · Ian Brownhill
Communication during a medical emergency in prison was confused, with no clear command structure established between prison staff, healthcare, and paramedics, indicating …
|
1/2 |