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 29 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
21 Jul 2025	Melissa Mathieson 2025-0367 · M. E. Voisin The care home provided misleading information on supervision levels and lacked formal induction periods, regular reviews for residents, and comprehensive updates to …	South West Avon	Alexandra Homes Ltd	1/1
18 Jul 2025	Marie Theobald 2025-0366 · Graeme Irvine Delays in a criminal investigation mean a suspect in a fatal road incident is unrestricted, posing a risk of further harm due …	London East London	London Metropolitan Police	1/1
18 Jul 2025	Dorothy Wagstaff 2025-0365 · John Hobson Ineffective temporary plastic road barriers that offer no resistance, allowing vehicles to leave the carriageway, remain present in gaps along the A660, …	Yorkshire and the Humber West Yorkshire (East)	Leeds City Council	1/1
18 Jul 2025	Patryk Gladysz 2025-0364 · Priya Malhotra Systemic failures include inadequate staffing affecting mental health assessments and key worker schemes, poor communication between prison and healthcare staff, and insufficient …	London Inner West London	HMPPS Minister of State for Prisons Ministry of Justice/HMP Wandsworth Oxleas NHS Foundation Trust	3/5
17 Jul 2025	Kaine Fletcher 2025-0363 · Alexandra Pountney A critical lack of shared understanding and adherence between emergency services regarding local policies and working standards for Section 136 detentions creates …	East Midlands Nottinghamshire	East Midlands Ambulance Service Nottingham and Nottinghamshire Police	2/2
18 Jul 2025	Darren Reilly and Tyler Cox 2025-0362 · Jacques Howell An unexplained gap in the motorway safety barrier, adjacent to established trees, poses a significant risk of severe injury or death if …	East of England Hertfordshire	National Highways	3/1
18 Jan 2024	Samuel Parkin 2025-0361 · Ellie Oakley Hospital learning points from a child's death were not formally disseminated, and ultrasound reports gave false reassurance about malrotation due to poor …	London Inner West London	NHS England St George’s University Hospitals NHS …	2/2
10 Jul 2025	Doreen Swann 2025-0359 · Alison Mutch Persistent delayed hospital discharges due to social care bed shortages force high-falls-risk patients to remain in acute settings, straining resources and potentially …	North West Manchester South	Greater Manchester Integrated Care Department of Health and Social …	2/2
15 Jul 2025	Alfie Lydon 2025-0358 · R Brittain Hospital trusts generally lack processes to document external calls from midwives, leading to poor continuity and escalation of care, especially regarding parental …	London Inner London North	NHS England Royal College of Paediatrics and …	2/2
11 Jul 2025	Myles Scriven 2025-0357 · Crispin Oliver The hospital failed to implement necessary adjustments for a patient with Learning Disabilities and Autism, with existing policies and training having no …	Yorkshire and the Humber West Yorkshire Western	Calderdale and Huddersfield NHS Foundation … CQC North NHS England	1/3
11 Jul 2025	Myles Scriven 2025-0356 · Crispin Oliver GPs demonstrated insufficient understanding of Learning Disability and Autism needs, resulting in inadequate adjustments and ineffective use of the Learning Disabilities Register, …	Yorkshire and the Humber West Yorkshire Western	CQC North Dalton Surgery NHS England	4/3
11 Jul 2025	Noreen McGlynn 2025-0355 · Mary Hassell There was a lack of capacity for community healthcare teams and GPs to offer home rehydration for a dehydrated patient, leading to …	London Inner North London	Central London Community Healthcare NHS … Mountfield Surgery	2/2
10 Jul 2025	Patricia Heaviside 2025-0354 · Rebecca Sutton The care home failed to implement recommended falls prevention equipment due to resource reluctance, didn't share critical information, and neglected to apply …	North East County Durham and Darlington	Care Quality Commission Durham County Council Howlish Hall Care Home Williams and Spenceley Limited	3/4
10 Jul 2025	Paul Ransom 2025-0353 · Henry Charles Thin surface treatments on roads can cause significantly reduced friction in early life, particularly dangerous for motorcycles in dry conditions, without adequate …	South East Hampshire, Portsmouth and Southampton	Association of Directors of Environment, … Department for Transport Road Surface Treatments Association	3/3
8 Jul 2025	Liliwen Thomas 2025-0352 · Rachel Knight Over-administration of analgesia during labour rendered the mother comatose, masking labour progression, and current national guidelines lack explicit detail on safe analgesia …	Wales South Wales Central	NICE	1/1
10 Jul 2025	Gemma Poterajko 2025-0351 · Elizabeth Didcock The absence of formal risk stratification and a written Standard Operating Procedure for lead extraction led to unclear planning and inadequate timely …	East Midlands Nottinghamshire	Nottingham University Hospitals NHS Trust	1/1
10 Jul 2025	Gavin Wheale 2025-0350 · Ian Dreelan The prison's secreted item policy inadequately addresses ingestion, and the handover from other agencies removes constant supervision, compromising the duty of care …	West Midlands Birmingham and Solihull	HM Prison & Probation Service	1/1
10 Jul 2025	Jairus Earl 2025-0349 · Rachael Griffin Significant gaps in shotgun licence regulation, including no requirement to declare multiple properties or movement, and less stringent application criteria compared to …	South West Dorset	Department of Health and Social … Home Office	3/2
9 Jul 2025	Shaun Marriott 2025-0348 · Joanne Andrews The day surgery patient assessment system lacks explicit requirements to question or record details about patients' haematological family history, or adequately document …	South East West Sussex, Brighton and Hove	Surrey and Sussex Healthcare NHS …	1/1
9 Jul 2025	Andrew Kenward 2025-0346 · Anna Loxton There is no central monitoring for sodium nitrite poisoning, and high-purity sodium nitrite can be easily imported and purchased in lethal quantities …	South East Surrey	Department of Health and Social … Home Office	2/2