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 |
|---|---|---|
| 8 Jul 2025 |
George Emmett
2025-0345 · Crispin Butler
An HMPPS staff member lacked familiarity with emergency medical response policies, potentially compromising timely, life-saving actions for prisoners in critical health situations.
|
1/3 |
| 8 Jul 2025 |
John Kirkman
2025-0344 · Paul Marks
Inconsistent IT systems prevent immediate sharing of mental health screening assessment results across regions, leading to a lack of vital background information …
|
1/1 |
| 7 Jul 2025 |
Patrick Coffey
2025-0343 · Robert Simpson
Inadequate and inconsistent recording of patient repositioning, with significant gaps in documentation, suggests patients, especially those at risk of chest infections or …
|
1/1 |
| 7 Jul 2025 |
Elaine Tarbuck
2025-0342 · Timothy Brennand
The "Right Care, Right Person" policy led to misclassification of a "concern for welfare" call, causing significant delays in emergency services forcing …
|
3/2 |
| 8 Jul 2025 |
Sean Fitzgerald
2025-0341 · Sir John Saunders
Inadequate national training and guidance on the timing of "armed police" announcements during tactical operations creates ambiguity, increasing risks of confusion and …
|
1/2 |
| 8 Jul 2025 |
Miles Robinson
2025-0340 · Sian Reeves
The ambulance triage system's rigidity incorrectly categorised a heart attack call as less urgent, lacking specific determinants for heart attack symptoms and …
|
0/2 |
| 7 Jul 2025 |
David Gifford
2025-0339 · Debbie Rookes
Paramedic training insufficiently addresses subtle presentations of vascular emergencies, like abdominal aortic aneurysms, increasing the risk of missed diagnoses when classic symptoms …
|
1/1 |
| 25 Oct 2024 |
Frank Ospina
2025-0338 · Lydia Brown
Mismatched healthcare and Home Office interpretations of Rule 35 led to a failure in reporting suicidal intentions, and an inappropriate "closed" visit …
|
3/3 |
| 7 Jul 2025 |
Sarah Lewis
2025-0337 · Debbie Rookes
Inconsistent and under-resourced ME services, coupled with a lack of professional understanding and research, hinder diagnosis, validation, and appropriate support for sufferers.
|
2/1 |
| 2 Jul 2025 |
Jason Clemens
2025-0336 · Guy Davies
The hospital lacked clear standard operating procedures and defined pathways for deteriorating renal patients, causing treatment delays and medication errors, despite similar …
|
1/1 |
| 7 Jun 2025 |
Ann Caldicott
2025-0335 · Sarah Clarke
Malnutrition and declining frailty were not adequately investigated by primary and secondary care, making the patient unsuitable for lifesaving treatment, compounded by …
|
2/2 |
| 4 Jul 2025 |
Daniel Hatchett
2025-0334 · Nadia Persaud
GP appointments and chronic disease review templates are inadequate for holistically assessing mental health decline in patients with chronic conditions, especially for …
|
2/2 |
| 30 Jun 2025 |
Thomas Mallinson
2025-0333 · Nicholas Shaw
An overcomplex system led to neglect, with no single body taking responsibility for the patient's urgent care. Failures included inappropriate advice, insufficient …
|
4/4 |
| 2 Jul 2025 |
Neil Clarke
2025-0332 · Christopher Murray
There were concerns about the suitability of surgical procedures for elderly patients without considering alternatives, and inaccurate handover communications for patients returning …
|
3/3 |
| 1 Jul 2025 |
Barry Spooner
2025-0331 · Nathanael Hartley
Inadequate information sharing by police with Adult Social Care means prior public protection notices are not consistently provided, hindering full risk assessment …
|
1/1 |
| 1 Jul 2025 |
Jody Robb
2025-0330 · Crispin Oliver
Inadequate physical barriers and non-deterrent design allowed track access, compounded by train crews failing to report a person on the tracks despite …
|
1/1 |
| 30 Jun 2025 |
Aaron Atkinson
2025-0329 · Peter Nieto
There is a concern that specialist services may not consistently retain responsibility for, or adequately monitor, the physical health of patients for …
|
2/5 |
| 29 Jun 2025 |
Leigh Nardelli
2025-0328 · Sean Cummings
National Highways knowingly delayed replacing hazardous P1 terminal designs for financial reasons, creating an ongoing safety risk for vehicles on designated roads.
|
1/1 |
| 27 Jun 2025 |
Brenda Fisher
2025-0327 · Chris Morris
Keeping patients for prolonged periods in unsuitable Emergency Department corridors, not designed for continuous care and observations, presents an inherent and residual …
|
1/1 |
| 26 Jun 2025 |
Jordanne Roberts
2025-0326 · David Reid
A locum doctor discharged a patient without reviewing the complete CT scan report, missing a pulmonary embolism. The Trust cannot confirm all …
|
1/1 |