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 28 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
29 Jul 2025	Thomas Hill 2025-0387 · Jason Pegg A flue-less gas heater was unsafely operated in a too-small room due to a hidden warning label, leading to carbon monoxide build-up. …	South East Hampshire, Portsmouth and Southampton	Office for Product Safety and …	1/1
18 Jul 2025	Jacqueline Langworthy 2025-0386 · Linda Lee The widespread use of platform lifts without hold-to-run controls in care settings, coupled with limited awareness of these risks and easy retrofitting …	West Midlands Coventry and Warwickshire	Department of Health and Social … HSE Lift and Escalator Industry Association	5/3
29 Jul 2025	Leslie Thompson 2025-0385 · Chris Morris A lack of evening and weekend physiotherapy services in hospitals causes discharge delays, leaving medically fit patients exposed to unnecessary risks within …	North West Manchester South	Department of Health and Social …	1/1
28 Jul 2025	Gareth Tatchell 2025-0384 · Aled Gruffydd Persistent delays in cancer diagnostic, staging, and treatment pathways, especially for staging scans, are adversely affecting patient survivability rates and prognoses, making …	Wales SWANSEA NEATH & PORT TALBOT	Swansea Bay University Health Board	2/1
25 Jul 2025	Kaine Fletcher 2025-0383 · Alexandra Pountney Concerns exist about emergency services' reliance on problematic terms like 'ABD', criticized for their potential to perpetuate racial bias and discrimination, despite …	East Midlands Nottinghamshire	College of Policing Custodial Services Department of Health and Social … East Midlands Ambulance Service	3/9
25 Jul 2025	Evelyn Chancellor 2025-0382 · Andrew Walker Insufficient staffing levels in care settings, especially when staff are distracted, compromise resident safety by reducing direct supervision.	London North London	Ashton Lodge Care Home	1/1
25 Jul 2025	Leia Sampson-Grimbly 2025-0381 · Andrew Walker Long waiting lists for first appointments at Gender Dysphoria clinics pose a significant risk, delaying crucial care for vulnerable individuals.	London North London	Department of Health and Social … Tavistock and Portman NHS Foundation …	2/2
25 Jul 2025	Robert English 2025-0380 · Andrew Walker Inadequate lighting on railway tracks and trains makes it difficult to locate trespassers at night, meaning current safety provisions are insufficient and …	London North London	Department of Transport Rail Safety Board Transport for London	3/3
25 Jul 2025	Jordan Babb 2025-0379 · Tom Osborne Failures in a walk-in centre to escalate abnormal vital signs, conduct structured risk assessments for pulmonary embolism, and properly apply clinical decision …	South East Milton Keynes	Milton Keynes Urgent Care Service	0/1
25 Jul 2025	Michael Pugh 2025-0378 · Patricia Harding Inadequate ACCT process training for new prison officers led to an incomplete understanding of observation requirements, including inconsistent timing and recording for …	South East Kent and Medway	His Majesty’s Prison and Probation …	1/1
25 Oct 2024	Wessam al Jundi 2025-0377 · Lydia Brown Workers fabricating artificial stone are exposed to unsafe conditions with inadequate dust suppression and PPE, causing rapid onset of untreatable silicosis. Current …	London West London	Department of Health & Social … Department of Housing, Community and … HSE	5/3
25 Jul 2025	Sheldon Jeans 2025-0376 · Rachael Griffin The absence of clear national and local policies on managing illicitly brewed alcohol ("hooch") and governing prisoner-held medications creates significant safety risks …	South West Dorset	Department of Health and Social … HMP Guys Marsh HMPPS Oxleas NHS Foundation Trust	4/4
25 Jul 2025	Samantha Young 2025-0375 · Henry Charles A lack of training for staff, especially agency staff, in mental health risk assessments, and persistent failure to engage and communicate with …	South East Hampshire, Portsmouth and Southampton	Department of Health and Social … Hampshire and Isle of Wight …	2/2
24 Jul 2025	James Scott 2025-0374 · Rosamund Rhodes-Kemp Inadequate gully maintenance, insufficient warning signage, and the continued presence of surface water on a known flood-risk road contributed to a fatal …	South East Hampshire, Portsmouth and Southampton	Hampshire County Council National Highways	1/2
22 Jul 2025	Isaac Ingle-Gillis 2025-0373 · Caroline Saunders The Crisis Resolution and Home Treatment Team's lack of access to GP records poses a future risk by preventing comprehensive mental health …	Wales Gwent	Aneurin Bevan University Health Board	1/1
19 May 2025	Emily Stokes 2025-0372 · Catherine Wood Private ambulance staff at a music event lacked adequate training for drug-affected patients and standard equipment, with unclear responsibility for pre-alert calls …	South East North East Kent	Kent Central Ambulance Service	1/1
18 Jul 2025	David Hayes 2025-0371 · Michael Pemberton Liquid washing detergent packaged deceptively like food and lacking safety features poses a severe ingestion risk, especially for vulnerable adults with dementia, …	North West Manchester West	Department of Environment Food and … Royal Society for Prevention of …	3/2
22 Jul 2025	Robyn Chambers 2025-0370 · Caroline Saunders Significant delays in ambulance dispatch were caused by prolonged handover times at emergency departments, potentially impacting patient care despite not affecting the …	Wales Gwent	Aneurin Bevan University Health Board Welsh Ambulance Service NHS Trust	1/2
21 Jul 2025	Christopher O’Donnell 2025-0369 · Ian Singleton The supported living accommodation's policy, which prohibits staff from removing excess medication for safeguarding without resident consent, creates a risk when residents …	South West Wiltshire and Swindon	Home Group Limited	1/1
21 Jul 2025	Madeline Reding 2025-0368 · Graeme Irvine Delayed and disorganised staff emergency response, including failures to promptly raise alarms or call 999, coupled with inadequate CPR due to a …	London East London	Aspray House Nursing Home	1/1