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 May 2025 |
Paul Alexander
2025-0244 · Peter Merchant
Police implemented the "Right Care, Right Person" policy without inter-agency consultation or a clear, agreed protocol for emergency services to respond to …
|
1/1 |
| 27 May 2025 |
Keith Inseon
2025-0243 · Andrew Cousins
Care home record-keeping was inaccurate and incomplete, as observation scores after a fall were not consistently recorded, hindering proper assessment for escalation …
|
1/1 |
| 23 May 2025 |
Lewis Johnson
2025-0242 · Mary Hassell
The IOPC's investigation terms of reference failed to include measuring vehicle distances during police pursuits, impacting the inquest by lacking objective evidence …
|
1/1 |
| 23 May 2025 |
Lewis Johnson
2025-0241 · Mary Hassell
The MPS failed to effectively implement and train staff on police pursuit policies, leading to inconsistent expectations among officers regarding the time …
|
1/1 |
| 21 May 2025 |
Robert Smith
2025-0240 · Andrew Morse
Mental health services lack clear guidance for clinicians on family information sharing and gathering, leading to inconsistent practices. Patient information leaflets also …
|
1/1 |
| 21 May 2025 |
Malcolm Morris
2025-0239 · John Thompson
Incompatible electronic systems prevent efficient patient referrals from regional hospitals to out-of-area district nursing, leading to delayed or absent post-discharge care, risking …
|
1/1 |
| 21 May 2025 |
Marina Waldron
2025-0238 · Caroline Saunders
During hospital admission, there was a prolonged failure to address the patient's inadequate nutritional intake, including neglecting family concerns, not monitoring diet, …
|
1/1 |
| 21 May 2025 |
David Bateman
2025-0237 · Guy Davies
Poor nursing care, which likely contributed to the patient's death and poses a risk to others, has not been shown to be …
|
1/1 |
| 21 May 2025 |
Etta-Lili Stockwell-Parry
2025-0236 · Kate Robertson
The neonatal investigation into the child's death was inadequate, failing to interview key staff and relying on incomplete records. Learning from the …
|
1/1 |
| 20 May 2025 |
Wayne Brown
2025-0235 · Louise Hunt
The fire service lacked policy for investigating work-related suicides and provided inadequate mental health support for senior staff, failing to record welfare …
|
1/1 |
| 17 May 2025 |
Joseph Powell
2025-0234 · Sarah Murphy
GPs failing to proactively book follow-up appointments for mental health patients, instead requiring them to self-book, often results in missed care and …
|
1/1 |
| 19 May 2025 |
Emmy Russo
2025-0233 · Thea Wilson
Hospital patient information on induction was incomplete regarding risks of prolonged pregnancy, and midwives showed inconsistent understanding of escalating concerns for labouring …
|
1/1 |
| 19 May 2025 |
John Charles Spencer
2025-0232 · Edward Steele
Incompatible computer systems prevent out-of-hours GP surgeries from accessing patient medical histories, even with consent, risking vital information not being conveyed for …
|
4/4 |
| 12 May 2025 |
Kenneth Foster
2025-0231 · Graeme Irvine
The Trust's patient safety framework, including incident reporting and mortality review processes, failed to identify and investigate a significant incident, risking future …
|
2/2 |
| 16 May 2025 |
Tina Doig
2025-0230 · Louise Hunt
The haematology department is severely understaffed and over capacity, leading to insufficient time for comprehensive patient reviews and increasing the risk of …
|
2/3 |
| 8 May 2025 |
James Sheppard
2025-0229 · Roland Wooderson
There is an insufficient number of psychiatric unit beds available to meet patient demand, posing a risk to those requiring mental health …
|
2/2 |
| 16 May 2025 |
Patricia Bushell
2025-0228 · Louise Pinder
National regulations for temporary road signage are inadequate, as compliant signage at a collision site was found to be insufficient, indicating a …
|
1/1 |
| 13 May 2025 |
Margaret Reeves
2025-0227 · Joanne Andrews
Inadequate information sharing with GPs risks patients receiving either no medication or excessive, duplicative prescriptions, posing a significant safety concern.
|
2/2 |
| 12 May 2025 |
Ian Simpson
2025-0226 · Ian Potter
The care home delayed calling an ambulance for an unresponsive resident and maintained inadequate, inaccurate records, including misleading and unlabelled retrospective entries, …
|
2/1 |
| 12 May 2025 |
Paul Reeves
2025-0225 · Ian Potter
Supported accommodation staff had unclear medication supervision roles and failed to communicate critical welfare concerns about a deteriorating resident to the mental …
|
1/1 |