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 37 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
16 Apr 2025	Freddie Slater 2025-0204 · Alan Blunsdon The absence of physical barriers on a grass verge separating two motorways creates a high risk of vehicles crossing into parallel lanes, …	South East North West Kent	Kent Police National Highways The Chief Coroner	1/3
25 Apr 2025	Jannat Abbker 2025-0203 · Mary Hassell A successful obstetric manoeuvre, the "shoulder shrug," is not included in NICE guidelines despite its use abroad, indicating a potential omission for …	London Inner North London	Royal College Obstetricians and Gynaecologists	1/1
23 Apr 2025	Martin Saunders 2025-01202 · Kerrie Burge Reduced visibility, permissible right turns from a parking bay, and speed limits on a particular road create a high risk of collisions. …	Wales South Wales Central	Rhondda Cynon Taf County Borough … Welsh Government	1/2
17 Apr 2025	Linda Sitch 2025-0201 · Sean Horstead Adult Safeguarding (ASC) failed to act on urgent referrals due to "human error" and inappropriate managerial downgrading of priority cases. ASC lacks …	East of England Essex	Essex County Council	1/1
24 Apr 2025	Jacqueline Potter 2025-0200 · Samantha Marsh Families of psychiatric patients on leave are not provided with codified risk and safety plans. Furthermore, secure unit Wi-Fi lacks filters, allowing …	South West Somerset	National Institute for Health and … NHS England Royal College of General Practitioners Royal College of Obstetricians and …	5/5
24 Apr 2025	Raymond Mills 2025-0199 · Samantha Goward No clear system exists to determine ownership and responsibility for shipwrecks accessible to the public, resulting in a lack of essential warning …	East of England Norfolk	Department for Transport	1/1
23 Apr 2025	Christopher Brazil 2025-0198 · Louisa Corcoran Unregulated online pharmacies easily sell prescription-only and controlled drugs, lacking patient verification, dosage guidance, and safeguards against misuse, exposing vulnerable individuals to …	Wales Ceredigion	Department for Digital, Culture, Media … Department of Health and Social …	2/2
17 Apr 2025	Peter Westwell, Mary Cunningham, Grace Foulds, Anne Ferguson 2025-0197 · James Adeley The UK's driver licensing system has lax visual acuity checks, relying on flawed self-reporting over decades. This enables drivers with impaired vision …	North West Lancashire and Blackburn with Darwen	Department for Transport	1/1
17 Apr 2025	Sheila Edwards 2025-0196 · James Adeley The driving licence system's reliance on self-reporting medical conditions, particularly dementia, is unsafe due to significant underreporting. This exposes other road users …	North West Lancashire and Blackburn with Darwen	Department for Transport	1/1
16 Apr 2025	Sarah Cunningham 2025-0195 · Mary Hassell Transport for London (TfL) has not implemented concrete plans to mitigate risks to intoxicated passengers, despite recognizing the issue and encouraging public …	London Inner North London	Transport for London	1/1
23 Apr 2025	Lorraine Parker 2025-0194 · Heidi Connor A lack of guidance means surgeons don't always consider CT scans for post-abdominal surgery patients with persistently high CRP. Over-reliance on clinical …	South East Berkshire	Association of Coloproctology of Great … Department of Health and Social … Royal College of Surgeons	4/3
23 Apr 2025	Lorraine Parker 2025-0193 · Heidi Connor The hospital's death investigation process is dysfunctional, characterized by delayed meetings, poor record-keeping, slow escalation, and unreliable medical record provision. Concerns about …	South East Berkshire	Royal Berkshire NHS Foundation Trust	1/1
16 Apr 2025	Abdulrahman Alajmi 2025-0192 · Ellie Oakley UK hospitals lack a set procedure for accepting international patients, often receiving individuals sicker than anticipated due to inaccurate information and insufficient …	London Inner West London	Department of Health and Social … Foreign, Commonwealth and Development Office Home Office NHS England	3/4
16 Apr 2025	Iris Carter 2025-0191 · Simon Brenchley A severe pressure sore developed before hospital discharge but was not properly inspected or adequately documented, indicating potential failures in skin assessment …	West Midlands Birmingham and Solihull	UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION …	1/1
15 Apr 2025	Samuel Brookes 2025-0190 · John Ellery A hospital discharged a patient without ensuring care arrangements were in place or that he could raise an alarm, leading to a …	West Midlands Shropshire, Telford & Wrekin	Russells Hall Hospital	0/1
11 Apr 2025	Patricia Catterall 2025-0189 · John Gittins The nursing home's pre-transfer assessment process was inadequate, relying on incomplete documentation and lacking face-to-face evaluations, resulting in missed critical patient information.	Wales North Wales (East and Central)	Betsi Cadwaladr University Health Board Pendine Park Care Organisation	2/2
11 Apr 2025	Susan Lakin 2025-0188 · I Thistlethwaite High-risk medical equipment, like an armchair belt, is sold online without warnings or professional guidance, exposing vulnerable users to serious risks such …	East Midlands Rutland and North Leicestershire	Department of Health and Social … Medicine and Healthcare Products and …	3/2
17 Feb 2025	Joshua Weavers 2025-0187 · Jacques Howell Nationally and locally, excessively long waiting times for Autism Spectrum Disorder (ASD) assessments delay crucial care and increase suicide risk, while local …	East of England Hertfordshire	Hertfordshire County Council Hertfordshire & West Essex Integrated … NHS England	3/3
10 Apr 2025	Ivy Dixon 2025-0186 · Ian Potter Care home staff provided inconsistent information about a patient's condition and failed to initiate CPR for a potentially reversible cardiac arrest, indicating …	London Inner North London	Lukka Care Homes Limited	1/1
4 Apr 2025	Alexi Susiluoto 2025-0185 · R Brittain Separate mental health and substance misuse services, compounded by patient homelessness, create significant confusion and gaps in care for individuals with dual …	London Inner North London	Department of Health and Social … Ministry of Housing, Communities and …	2/2