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 |
|---|---|---|
| 17 Jun 2025 |
Sonia Sore
2025-0305 · Darren Stewart
The care home demonstrated a cultural problem of inadequate risk assessment and mitigation, with staff consistently failing to implement identified safety measures …
|
1/1 |
| 17 Jun 2025 |
Greta Lewis
2025-0304 · Philip Spinney
There is a critical gap in the availability of the time-sensitive thrombectomy procedure for severe stroke patients across the South West region.
|
2/1 |
| 17 Jun 2025 |
Hazel Gambles
2025-0303 · Simon Tait
There were systemic failures in documentation and adherence to Trust policy regarding falls assessment, prevention measures, timely medical reviews, and family communication …
|
4/1 |
| 13 Jun 2025 |
Valerie Hill
2025-0302 · Graeme Hughes
Long-standing, systemic ambulance handover delays in Wales persist at intolerable levels, with risks remaining due to a disconnect between ambulance service rostering …
|
1/1 |
| 13 Jun 2025 |
Valerie Hill
2025-0301 · Graeme Hughes
The care home lacks effective staff training on falls risk identification, documentation, and mitigation, with assessments often missing professional counter-signatures and a …
|
1/1 |
| 16 Jun 2025 |
Norma Campbell
2025-0300 · Nadia Persaud
Whipps Cross A&E experiences severe overcrowding, inadequate staffing, and insufficient resuscitation beds, leading to critically ill patients receiving substandard care in corridors …
|
1/1 |
| 13 Jun 2025 |
Chloe Ellis
2025-0298 · Oliver Longstaff
Lack of commissioning means NHS 111 online assessment outcomes are not accessible to Emergency Department clinicians, hindering comprehensive history taking and failing …
|
1/1 |
| 13 Jun 2025 |
Sally Burr
2025-0297 · Joseph Turner
Detained mental health patients can exploit mobile internet access to research self-harm methods, as staff lack effective technical means to monitor or …
|
1/1 |
| 12 Jun 2025 |
Michael Barry
2025-0296 · Sean Horstead
There is a critical lack of commissioned specialist services for GPs to safely manage patients reducing or withdrawing from prescribed dependency-forming medications, …
|
3/3 |
| 12 Jun 2025 |
Simon Hockenhull
2025-0295 · Elizabeth Wheeler
Inconsistent definitions of a 'month' for diabetic medication prescriptions cause supply challenges, leading to inconsistent patient adherence and potential life-threatening health impacts.
|
1/1 |
| 12 Jun 2025 |
Carol Taylor
2025-0294 · Stephen Simblet
No system prevents staff non-compliant with mandatory training, including basic life support, from working on inpatient wards, posing a particular risk to …
|
3/1 |
| 11 Jun 2025 |
Maureen Powell
2025-0293 · Gordon Clow
Widespread non-compliance with daily skin inspections, inadequate care plan updates, and delays in pressure ulcer management, compounded by poor record-keeping, led to …
|
1/1 |
| 5 Jun 2025 |
David Bendell
2025-0292 · Nigel Parsley
A lack of step-down community rehabilitation facilities for patients not eligible for inpatient care but too frail for home-only support risks unsafe …
|
1/1 |
| 11 Jun 2025 |
Lila Marsland
2025-0291 · Chris Morris
The Child Sepsis Screening Tool is not fully embedded, meningitis guidelines are not completely implemented, and fragmented record-keeping across systems risks vital …
|
2/2 |
| 10 Jun 2025 |
Andrew Connolly
2025-0290 · Alison Mutch
GPs' reliance on telephone appointments for mental health assessments and lack of family input led to unrecognized patient risks due to absent …
|
1/1 |
| 10 Jun 2025 |
Amy Levy
2025-0289 · Robert Sowersby
Police failed to leave voicemail messages when attempting to contact family members during a critical emergency, potentially delaying location and aid for …
|
3/3 |
| 5 Jun 2025 |
Thomas Oldcorn
2025-0288 · Margaret Taylor
Inadequate resources have led to significantly prolonged waiting times for cardiac surgery after angiography, consistently exceeding national targets and increasing to 17 …
|
1/1 |
| 16 Sep 2022 |
Nargis Begum
2025-0287 · Nicola Mundy
The public lacks crucial understanding and awareness regarding their responsibility to report motorway incidents, despite existing SMART motorway campaigns, leaving stationary vehicles …
|
1/1 |
| 6 Jun 2025 |
Frederick Ireland-Rose
2025-0286 · Sarah Bourke
Cannabinoid vape users are unaware of the significant and variable risk of nitazene adulteration in vaping fluids and lack access to Naloxone, …
|
2/2 |
| 19 Mar 2025 |
Benjamin Compton
2025-0285 · Philip Spinney
A significant gap in care exists for autistic individuals in crisis without a treatable mental health condition, and the Special Allocation Scheme …
|
3/4 |