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 33 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
6 Jun 2025	Esme Atkinson 2025-0284 · Alison Mutch Insufficient training for community healthcare professionals in identifying infant heart defects, especially with maternal diabetes, and inadequate auditing of cardiac anomaly scans …	North West Manchester South	Department of Health and Social … Greater Manchester Integrated Care Board	2/2
5 Jun 2025	Nicholas Gray 2025-0283 · Sonia Hayes The Trust's PSIRF Decision Monitoring Tool contained inaccurate and incomplete information regarding patient contact and self-harm, undermining potential investigation requirements.	East of England Essex	Essex Partnership University NHS Trust	1/1
3 Jun 2025	Anthony Wood 2025-0282 · John Taylor A high-risk, severely frail patient fell due to inadequate falls prevention, including missing crash mats, a lowered bed-rail, and only one staff …	London South London	Epsom and St. Helier University …	0/1
5 Jun 2025	Edward Wilson 2025-0281 · Jacqueline Devonish Paramedics failed to consider the patient's significant heart failure history when administering salbutamol nebulisers, which directly impacted the outcome by lowering blood …	North West Cheshire	North West Ambulance Service	1/1
26 May 2025	Sarah Hill 2025-0280 · Margaret Taylor Inadequate falls risk assessments, poor documentation, and infrequent observations for a deteriorating patient were compounded by unsafe side-room placement and severe understaffing.	North West Cumbria	North Cumbria Integrated Care NHS …	1/1
29 May 2025	Jeanette Sidlow Beech 2025-0279 · Kate Robertson Critical ambulance delays, exacerbated by significant hospital handover issues and a lack of social care, lead to patients awaiting discharge, blocking emergency …	Wales North Wales (East and Central)	Betsi Cadwaladr University Local Health … Local Authorities within this jurisdiction Welsh Ambulance Service Trust Welsh Government	1/4
5 Jun 2025	Cain Donald 2025-0278 · Nicholas Graham Deficiencies in discharge planning from a psychiatric unit, including inadequate engagement with family and probation, and a failure to supervise post-discharge medication …	South East Oxfordshire	Oxford Health NHS Foundation Trust	1/1
3 Jun 2025	Pellumb Olaj 2025-0277 · Mary Hassell The council failed to consider a patient's history of paranoid schizophrenia and past suicide attempts by jumping from high places when housing …	London Inner North London	Islington Council	1/1
5 Jun 2025	Colin Brooks 2025-0276 · Simon Brenchley Insufficient on-call perfusionist staffing during simultaneous emergency surgeries, not meeting safety guidelines, risks delays in identifying critical issues during cardiopulmonary bypass procedures.	West Midlands Birmingham and Solihull	Department of Health and Social …	1/1
3 Jun 2025	Benjamin Arnold 2025-0275 · Oliver Longstaff Maternity services are unequally split with limited support and no on-site paediatric cover at one site. Concerns also include ambiguous unit classification …	Yorkshire and the Humber West Yorkshire (East)	British Association of Perinatal Medicine Department of Health and Social … Leeds Teaching Hospitals NHS Trust Resus Council UK	7/5
4 Jun 2025	David Heffer 2025-0274 · Sonia Hayes The treating doctor was not informed of the patient's readmission for a complication, and medical records were incomplete and illegible, hindering proper …	East of England Essex	East Suffolk and North Essex …	1/1
4 Jun 2025	David Ejimofor 2025-0273 · Edward Ramsay The absence of lifeguards at a dangerous breakwater during high-risk periods, despite historical effectiveness, and insufficient evidence that new deterrence measures are …	Wales Swansea and Neath Port Talbot	ASSOCIATED BRITISH PORTS NEATH PORT TALBOT COUNCIL ROYAL NATIONAL LIFEBOAT INSTITUTION	3/3
3 Jun 2025	Esther Byrne 2025-0272 · Janine Richards Poor communication with family and power of attorney led to incorrect baseline information for discharge planning, misunderstandings among medical staff, and the …	North East Durham and Darlington	No addressees parsed	1/0
30 May 2025	Brian Garrick 2025-0271 · Stephen Covell Ambulance response times are severely delayed due to prolonged patient handovers at acute hospitals, preventing crews from returning to service.	South West The County of Devon, Plymouth and …	Department of Health and Social …	1/1
2 Jun 2025	Charlotte Werner 2025-0270 · Mary Hassell A lack of clear communication led to a misunderstanding that a dietetic service treated eating disorders, highlighting a need for clarification that …	London Inner North London	University College London Hospitals NHS …	0/1
3 Jun 2025	Mark Villers 2025-0269 · Louise Hunt Insufficient radiologists led to a critical abnormality (aortic dissection) being missed on a CT scan, with current staffing levels still below guidelines, …	West Midlands Birmingham and Solihull	Department of Health and Social … University Hospitals Birmingham NHS Foundation …	2/2
2 Jun 2025	Michelle Mason 2025-0268 · Christopher Long Lancashire lacks a 24/7 thrombectomy service and a clear plan for its delivery, compounded by non-stroke specialists' misunderstanding of service availability and …	North West Lancashire and Blackburn with Darwen	Lancashire Teaching Hospitals NHS England Northern Care Alliance NHS Foundation …	5/3
2 Jun 2025	Patrick Mongan 2025-0267 · N J Mundy A mound of earth on the motorway central reservation creates a dangerous hazard, causing loss of vehicle control and risking catastrophic accidents …	Yorkshire and the Humber South Yorkshire East	National Highways	1/1
30 May 2025	Eric Swaffer, Izabela Lechowicz, Khun Vichai Srivaddhanaprabha, Nusara Suknamai … 2025-0266 · Catherine Mason The design and safety supervision of helicopters are concerning, specifically regarding the inadequate provision of system and flight-testing data from aircraft manufacturers …	East Midlands Leicester City and South Leicestershire	Civil Aviation Authority European Union Aviation Safety Authority	2/2
30 May 2025	Colin Lovett 2025-0265 · Rachael Griffin Prison staff lack essential diabetes training and understanding of critical attacks. Non-24/7 healthcare and poor awareness among staff risk delayed care and …	South West Dorset	Department of Health and Social … HMPPS	2/2