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 |
|---|---|---|
| 27 Jun 2025 |
Susan Clissold
2025-0325 · Jacqueline Lake
Insufficient district nursing staff and increasing patient complexity led to missed appointments and an inability to provide consistent care, despite internal measures …
|
1/1 |
| 26 Jun 2025 |
Michael Kerslake
2025-0324 · Vanessa McKinlay
A crucial risk assessment for operating machinery near electrical equipment was absent, and this safety gap persists at other sites owned by …
|
1/1 |
| 26 Jun 2025 |
Callan Atkins
2025-0323 · Roland Wooderson
Mental health crisis team capacity directly impacts same-day assessments, and the Trust does not secure additional resources when local teams lack capacity, …
|
0/1 |
| 24 Jun 2025 |
Susan Young
2025-0322 · Yvonne Blake
Critical failures included no clinical handover, missing doctor's instructions for cardiac monitoring, and the patient retaining personal medication, creating a risk of …
|
2/1 |
| 31 Mar 2025 |
Andrew Tizard-Varcoe
2025-0321 · Philip Spinney
Fragmented care across multiple health trusts resulted in clinicians lacking complete patient information and unclear responsibilities, compounded by untimely follow-up appointments and …
|
2/2 |
| 24 Jun 2025 |
Karl Dunstan
2025-0320 · Tom Osborne
Pulmonary embolism investigation deviated from NICE guidance; radiology rejected a CTPA without completing a D-dimer test that, if positive, would have necessitated …
|
1/1 |
| 23 Jun 2025 |
David Walsh
2025-0319 · Marianne Johnson
Delayed reporting of road traffic collisions by Police to the Highways Department (annual review vs. immediate) prevents timely identification and intervention for …
|
1/2 |
| 23 Jun 2025 |
Louise Crane
2025-0318 · Ian Potter
A significant safety concern is the absence of a nationwide policy or consistent approach to anti-ligature measures within mental health facilities.
|
2/2 |
| 23 Jun 2025 |
Louise Crane
2025-0317 · Ian Potter
Inaccurate record-keeping, a widespread lack of therapeutic engagement understanding among staff, and systemic failures during step-down from PICU hindered safe patient transition …
|
1/1 |
| 20 Jun 2025 |
Finlay Roberts
2025-0316 · Mary Hassell
There is a concerning widespread lack of serial paediatric nursing observations, with medical staff failing to identify their absence, leading to an …
|
4/4 |
| 18 Jun 2025 |
Edward Cassin
2025-0315 · Sean Cummings
There was a lack of understanding of Speech and Language Therapy and Dietetic policies among hospital staff, compounded by siloed working between …
|
2/2 |
| 23 Jun 2025 |
REDACTED
2025-0314 · Andrew Hetherington
Inadequate face-to-face weight monitoring, confusion over consultant-to-consultant referrals, and discharge from CAMHS without direct patient contact or engagement exploration were significant concerns. …
|
5/5 |
| 20 Jun 2025 |
Patrick Viles
2025-0313 · R Brittain
A doctor prescribed medication to a patient with known suicidal ideation shortly after a psychologist recommended urgent psychiatric input, raising concerns about …
|
1/2 |
| 19 Jun 2025 |
Vera Fortey
2025-0312 · David Reid
Poor documentation of an unwitnessed fall, delayed medical attention despite clear patient deterioration, and inadequate staff training contributed to missed opportunities for …
|
1/1 |
| 5 Jun 2025 |
Richard Osman
2025-0311 · Mark Layton
Cockpit fire/smoke procedures need a full review for oxygen fire recognition and protective equipment. International civil aviation investigation protocols require amendment for …
|
3/4 |
| 18 Jun 2025 |
Terence Colby
2025-0310 · Darren Stewart
A GP failed to perform a basic vascular examination for a patient presenting with a foot wound and leg pain, contrary to …
|
2/1 |
| 18 Jun 2025 |
Margaret Douglas
2025-0309 · Charlotte Keighley
The care home accepted a patient despite being unable to meet her complex one-to-one care needs, and outsourced carers lacked adequate communication …
|
1/3 |
| 17 Jun 2025 |
Upali Meththananda
2025-0308 · Catherine Wood
Poor clinical documentation, including absent observations, key event records, and inter-clinician discussions, meant treating clinicians lacked a full patient picture, risking future …
|
1/1 |
| 18 Jun 2025 |
Charlotte Alderson
2025-0307 · Darren Stewart
Inconsistent infection scoring systems, a lack of rapid sepsis identification tools, and failures in the 111/999 information handover system risk critical delays …
|
1/1 |
| 18 Jun 2025 |
Valerie Hampson
2025-0306 · Chris Morris
The Trust failed to investigate the progression of a severe leg wound under district nurse care, and a recommended orthopaedic follow-up from …
|
1/1 |