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 |
|---|---|---|
| 5 Nov 2024 |
Terence Gillard
2025-0264 · Jeane Mellani
A dangerous uncontrolled pedestrian crossing on a multi-lane 40mph road lacks safety features and has a history of accidents. Redesign plans are …
|
3/3 |
| 29 May 2025 |
Callum Hargreaves
2025-0263 · Andrew Cox
The rationale for not detaining a patient was unrecorded. Clinicians failed to adequately test or challenge his decision to withhold discharge information …
|
1/1 |
| 29 May 2025 |
Callum Hargreaves
2025-0262 · Andrew Cox
The rationale for not admitting a patient with complex PTSD/EUPD was unrecorded. Clinicians failed to explore or challenge his refusal to inform …
|
1/1 |
| 28 May 2025 |
Callum Hargreaves
2025-0261 · Andrew Cox
A prolonged dispute between a social housing provider and the Council over rehousing a cuckooed tenant remained unresolved, highlighting a failure to …
|
1/1 |
| 28 May 2025 |
Callum Hargreaves
2025-0260 · Andrew Cox
Sanctuary Housing failed to properly investigate cuckooing and property damage for a vulnerable tenant, leading to an eviction notice instead of support, …
|
1/1 |
| 28 May 2025 |
Callum Hargreaves
2025-0259 · Andrew Cox
A severe shortage of available housing in Cornwall, with high demand and low supply, contributed to the deceased's homelessness and exacerbated his …
|
1/1 |
| 23 May 2025 |
Andrew Brown
2025-0258 · Timothy Brennand
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly …
|
1/1 |
| 23 May 2025 |
William Armstrong
2025-0257 · Timothy Brennand
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly …
|
0/1 |
| 23 May 2025 |
Kelly Walsh
2025-0256 · Timothy Brennand
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly …
|
0/1 |
| 23 May 2025 |
Chantelle Williams
2025-0255 · Timothy Brennand
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly …
|
1/1 |
| 23 May 2025 |
Mathew Price
2025-0254 · Timothy Brennand
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly …
|
1/1 |
| 23 May 2025 |
Shaun Bass
2025-0253 · Timothy Brennand
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly …
|
1/1 |
| 23 May 2025 |
Samuel Dickenson
2025-0252 · Timothy Brennand
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly …
|
1/1 |
| 23 May 2025 |
Matthew O’Reilly
2025-0251 · Timothy Brennand
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly …
|
1/1 |
| 28 May 2025 |
Julie Beasley
2025-0250 · Sonia Hayes
Inadequate mental health assessments, medication errors, and poor communication with the GP and patient led to missed opportunities to gather critical information. …
|
1/1 |
| 30 Sep 2019 |
Ceara Thacker
2025-0249 · Anita Bhardwaj
Professionals failed to discuss family involvement in care planning for a young adult with mental health issues. Additionally, the residential advisor lacked …
|
1/2 |
| 28 May 2025 |
Dean Bradley
2025-0248 · Clare Bailey
Current resources for safeguarding intoxicated individuals with mental health illnesses are insufficient, as assessments cannot occur until sobriety, leaving vulnerable people at …
|
7/7 |
| 23 May 2025 |
George Fraser
2025-0247 · Nadia Persaud
The Mental Health and Wellness Team failed to establish a clear care plan or robust risk assessment. They also neglected to act …
|
1/1 |
| 27 May 2025 |
Sophie Cotton
2025-0246 · Rebecca Sutton
Police applying "Right Care, Right Person" policy refused attendance despite immediate risk and multiple calls, disregarding mental health teams' inability to enter …
|
4/2 |
| 27 May 2025 |
Abdirahman Afrah
2025-0245 · Nadia Persaud
A&E had excessive waiting times and lacked timely medical triage, risking critical patient deterioration. Follow-up calls were made without full clinical information …
|
1/1 |