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 36 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
12 May 2025	James Smith 2025-0224 · Guy Davies Inadequate social care provision leads to hospital discharge backlogs, causing severe ambulance handover delays and ED crowding, significantly increasing mortality risks for …	South West Cornwall and Isles of Scilly	Department of Health and Social …	1/1
13 May 2025	Rose Harfleet 2025-0223 · Karen Henderson The hospital lacked guidance for managing children with profound disabilities, failed to adequately consult or respond to their parents, and did not …	South East Surrey	Care Quality Commission Department of Health and Social … NHS England Royal College of Emergency Medicine	6/6
9 May 2025	Caroline and Bernard Cleall 2025-0222 · Ivor Collett Adult Social Care's inability to access NHS hospital discharge assessment records for telecare prevents proper review of client needs, risking inadequate support …	London South London	London Borough of Croydon	1/1
9 May 2025	John England 2025-0221 · Andrew Cox The ambulance service's dispatch system lacks nuance for specific abdominal complaints, leading to an inappropriately low emergency category and delaying critical care …	South West Cornwall and Isles of Scilly	NHS England	1/1
9 May 2025	Jake Lawler 2025-0220 · Alison Mutch Clinicians frequently misinterpret ECGs and lack clear national guidance for paediatric exercise-induced syncope. The national asthma scoring system is insufficient, leading to …	North West Manchester South	Department of Health and Social …	1/1
9 May 2025	Janet Anderson 2025-0219 · Alison Mutch A prolonged hospital stay due to inadequate community placement and poor inter-trust collaboration, coupled with poor documentation, significantly contributed to the patient's …	North West Manchester South	Greater Manchester Integrated Care Board Greater Manchester Mental Health Manchester University NHS Foundation Trust	3/3
8 May 2025	Dorothy Gamby 2025-0218 · Melanie Lee Widely available wide/clawed ferrules for walking sticks lack crucial warnings about potential trip and trapping risks, particularly when used with folding designs.	London Inner North London	Office for Product Safety and …	1/1
7 May 2025	Sybil Morgan-Gray 2025-0217 · R Brittain Blood gas machines display unrecordably low glucose in a way that can be misinterpreted as an unanalysable sample, potentially delaying appropriate clinical …	London Inner North London	Medicines and Healthcare Products Regulatory …	1/1
6 May 2025	John Johnson 2025-0216 · James Thompson Hospital Trusts use multiple IT systems that don't integrate, leading to fragmented patient information, a risk of critical findings being missed, and …	North East Gateshead and South Tyneside	Department of Health and Social …	1/1
2 May 2025	Paul Burke 2025-0215 · Jacques Howell Persistent, multi-factorial delays in ambulance response times, coupled with hospital handover issues and system pressures, are causing significant waits for urgent pre-hospital …	East of England Hertfordshire	Department of Health and Social …	1/1
2 May 2025	Rosemary MacAndrew 2025-0214 · Beth Brown The vehicle licensing system relies on older drivers, including those with cognitive decline, to self-report medical conditions. This self-reporting is inadequate and …	East Midlands Nottingham and Nottinghamshire	Department for Transport	1/1
6 May 2025	Charlotte Avis 2025-0213 · Rachael Griffin A specific crossroads has a history of numerous serious and fatal collisions, and concerns remain regarding the road layout despite a speed …	South West Dorset	Department for Transport Dorset Council	2/2
2 May 2025	Raihana Oluwadamilola Awolaja 2025-0212 · Fiona J Wilcox A child requiring 1:1 tracheostomy care died due to inadequate supervision and insufficient staffing, leading to a blocked tracheostomy. This represents a …	London Inner West London	Children’s Trust	1/1
2 May 2025	Sarah Boyle 2025-0211 · Victoria Davies The ACCT process at HMP Styal is ineffective for preventing self-harm, lacking therapeutic mental health input. The prison holds many complex patients …	North West Cheshire	HMP Styal HMPPS Prisons, Probation and Reducing Reoffending Ministry of Justice	1/4
3 Apr 2025	Alexander Cardoza 2025-0210 · Alison Hewitt Despite previous deaths, barriers at a specific location remain surmountable due to design flaws and insufficient operational security, including a lack of …	London City of London	1. [REDACTED], and 2. [REDACTED]	2/2
1 May 2025	Peter Anzani 2025-0209 · Adam Hodson Patient observations were not adequately recorded, possibly due to a lack of staff training. Additionally, significant hospital waiting lists and prolonged patient …	West Midlands Birmingham and Solihull	Department of Health and Social … NHS England Robert Jones and Agnes Hunt …	2/3
30 Apr 2025	Doreen Turner 2025-0208 · Joanne Andrews A residential cul-de-sac lacks adequate barriers and standard height kerbing at its end, allowing vehicles to repeatedly enter an adjacent canal, posing …	South East West Sussex, Brighton and Hove	West Sussex County Council	1/1
30 Apr 2025	Louise Rosendale 2025-0207 · Alison Mutch The practice failed to conduct sufficient long-term review and oversight of a patient's long-term opiate prescription, despite the associated risks, indicating a …	North West Manchester South	Flixton Road Medical Centre Greater Manchester Integrated Care Board	2/2
25 Apr 2025	Richard Moss 2025-0206 · Jonathan Heath Medical practitioners must manually select an option to alert colleagues about new referral documents, instead of alerts being automatically generated, risking un-actioned …	Yorkshire and the Humber North Yorkshire and York	Townhead Surgery	2/1
16 Apr 2025	Marina Raisbeck 2025-0205 · Elizabeth Didcock No systems exist for prioritizing or monitoring the clinical parameters of urgent surgical patients awaiting transfer between emergency departments and receiving hospitals.	East Midlands Nottinghamshire	Doncaster and Bassetlaw Teaching Hospitals …	1/1