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 3 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
30 Mar 2026	Ethan Hanson 2026-0229 · Linda Lee Absence of computerised safeguards risked incorrect recording of observations, and critical GP information was not transferred to the hospital. Concerns were also …	West Midlands Warwickshire	College of General Practitioners NHS England, George Eliot Hospital …	3/2
30 Apr 2026	Kevin Lapwood 2026-0238 · Heidi Connor Concerns were raised about insufficient training for volunteer divers regarding medical requirements and immersion pulmonary oedema risks. There is also a lack …	South East Berkshire	British Diving Safety Group Health and Safety Executive	2/2
30 Apr 2026	Joseph Cooper 2026-0237 · Chris Morris There is an absence of commissioned services for co-occurring mental health and substance misuse conditions, and large quantities of alcohol are easily …	North West Greater Manchester South	Department of Health and Social …	2/1
29 Apr 2026	REDACTED 2026-0245 · James Bennett NHS England guidance lacks provisions for managing staff accused of sexual misconduct, particularly regarding risk assessment, police notification, and decisions on suspension …	West Midlands Birmingham and Solihull	NHS England	1/1
26 May 2026	Kristian Allen 2026-0241 · Gareth Jones Concerns included staff authorising escorted leave despite patients testing positive for drugs due to ignorance of conditions. Additionally, responses to cardiac arrests …	South East West Sussex, Brighton and Hove	Sussex Partnership Foundation Trust	1/1
21 Apr 2026	Theresa Lydon 2026-0244 · James Thompson Consultant letters to GPs lacked clear formatting for treatment plans, and specialists could not issue initial prescriptions directly. Additionally, patient medical records …	North East Gateshead & South Tyneside	Department of Health and Social …	2/1
24 Apr 2026	Edward Muwanga 2026-0235 · Paul Rogers Concerns were raised regarding police officers' understanding of mental health powers under sections 135 and 136 MHA, and the fragmented sharing of …	London Inner West London	London Ambulance Service NHS Trust NHS England One London Board South London and Maudsley NHS …	6/6
24 Apr 2026	Michelle Dawes 2026-0228 · Isobel Thislethwait The Trust acknowledged delays and missed opportunities in patient care, but concerns were raised that identified changes to improve patient safety have …	West Midlands The Black Country	Walsall Healthcare NHS Trust	1/1
24 Apr 2026	Kenneth Morris 2026-0227 · Paul Marks Insufficient staffing meant the deceased did not receive required one-to-one nursing care, leading to a fall and death. The coroner noted that …	Hull and East Riding	Secretary of State for Health	1/1
17 Mar 2026	Scott Catton 2026-0240 · Karen Boyle The absence of a legal requirement for electric scooter riders to wear helmets raises concerns about the risk of death from head …	East Midlands Nottingham and Nottinghamshire	1. Secretary of State for … Secretary of State for Transport1.CORONERI …	2/2
23 Apr 2026	Stephanie Link 2026-0224 · Simon Brenchley The absence of a finalised and agreed care pathway for complex acute pancreatitis, accessible and understood by clinicians across different hospital sites, …	West Midlands Birmingham and Solihull	University Hospitals Birmingham NHS Foundation …	1/1
20 Apr 2026	Paul Harries 2026-0242 · Joseph Turner Concerns exist regarding manual coding errors in the GP-Consultant surgeon booking chain, which can prevent urgent referrals from being actioned or explained. …	South East West Sussex, Brighton and Hove	University Hospitals Sussex NHS Foundation …	1/1
10 Apr 2026	Garry Mills 2026-0212-wp126189 · Darren Stewart The £250 per week allowance for living expenses in Proceeds of Crime Act Restraint Orders has not been reviewed since 2009, making …	South East Surrey	Attorney General of England and …	0/1
9 Feb 2026	Ellen Taylor 2026-0236 · Sarah Middleton There were no national guidelines for nasogastric tube insertion in patients with previous gastric surgery, and altered anatomy was not readily apparent …	North East Northumberland	1. NHS England NHS England1CORONER I am Miss …	1/2
16 Apr 2026	Roger Ginger 2026-0218 · Ronald Wooderson A recommendation from the Professional Standards Department, made in a report dated 9 July 2025, may not have been actioned.	South West Gloucestershire	Chief Constable for the Gloucestershire …	1/1
n/a	Sean Williams 2026-0234 · Mary Hassell The custody nurse did not adequately assess Mr Williams or record vital signs before prescribing medication. Serco staff showed delays and inadequate …	London Inner North London	MPS SERCO	2/2
23 Apr 2026	Thomas Mayhew 2026-0225 · Laura Bradford Concerns were raised that routing emergency calls about apparently deceased persons to the police before the ambulance service, as per the PECS …	South East East Sussex	Department for Science, Innovation and … National Police Chiefs’ Council	2/2
6 Mar 2026	Kay Wilson 2026-0132-wp123915 · Jeremy Chipperfield A breach in a stone wall near County Bridge, Barnard Castle, allows unrestricted access to a 9-meter drop onto rocks and the …	North East County Durham and Darlington	Durham County Council	1/1
24 Apr 2026	Ellie Herron 2026-0226 · Paul Marks The park is frequented by individuals who sell and abuse drugs, drink alcohol, and sleep rough; this puts vulnerable individuals at high …	Hull and East Riding	Chief Constable of Humberside Police	1/1
15 Apr 2026	David Roomes 2026-0222 · Ian Potter The report identifies a significant delay in triaging referrals, compounded by a poorly executed initial triage, potentially reflecting a wider training issue …	South East Kent and Medway	Kent & Medway NHS Mental …	0/1