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 |
|---|---|---|
| 10 Apr 2025 |
Jonathan Hamer
2025-0184 · Lydia Brown
Gaps in community mental health care due to staff absences and issues with supported housing transitions contributed to a patient's deteriorating condition …
|
1/1 |
| 10 Apr 2025 |
Joel Ineson
2025-0183 · David Place
Organised open water swimming events lack clear safety responsibilities, specific briefings, participant oversight, and regulatory guidance, creating significant unmanaged risks.
|
2/2 |
| 7 Feb 2025 |
Ella Murray
2025-0182 · Catherine Wood
Failures in urgent safeguarding, lack of shared information access between health, social care, and education agencies, and an inability to convene urgent …
|
2/3 |
| 10 Apr 2025 |
Robert Smith
2025-0181 · Alison Mutch
Significant waiting lists for mental health therapies, including Interpersonal Therapy, are preventing patients from accessing essential support in a timely manner due …
|
1/2 |
| 9 Apr 2025 |
Emma Hill
2025-0180 · John Gittins
Obstructed visibility at a road junction and high traffic speeds following a speed limit change create an ongoing risk of serious collisions …
|
1/1 |
| 9 Apr 2025 |
Bernard Lyon
2025-0179 · Alison Mutch
Systemic failures include an under-managed care home using agency staff with language barriers, poor inter-agency communication, and severe overcrowding in hospital emergency …
|
3/3 |
| 3 Apr 2025 |
Loraine Cheesman
2025-0178 · Crispin Oliver
There is a lack of specific national guidance for assessing mental capacity in adults with Hoarding Disorder and Executive Dysfunction, hindering effective …
|
1/1 |
| 8 Apr 2025 |
Ruth Pingree
2025-0177 · Darren Stewart
Fire safety regulations for paid accommodation lack clear standards, mandatory records, and specific risk assessment guidance, leading to potential shortcuts and misunderstandings …
|
1/2 |
| 7 Apr 2025 |
Christian Hobbs
2025-0176 · David Heming
Key recommendations to improve cardiogenic shock care, including staff awareness, out-of-hours echocardiography access, and defined pathways, are not adequately funded or implemented …
|
8/8 |
| 7 Apr 2025 |
Sandra Millard
2025-0175 · Robert Simpson
The NHS Pathways triage tool does not consistently prompt additional questions for patients unable to move from any position, potentially missing risks …
|
2/2 |
| 3 Apr 2025 |
Andrew Waters
2025-0174 · Guy Davies
Significant ambulance handover delays, emergency department crowding, and inadequate social care provision are leading to increased mortality risk for patients awaiting emergency …
|
1/1 |
| 6 Apr 2025 |
June Thompson
2025-0173 · Guy Davies
Major operations proceeded without surgical teams having full knowledge of disease progression, resulting from unreported errors and a lack of policy for …
|
1/1 |
| 7 Apr 2025 |
Christopher McDonald
2025-0172 · Sian Reeves
Psychiatric unit staff lacked understanding and adherence to the 'AWOL - Missing & Absent Persons Policy,' failing in individualized assessments, police accompaniment, …
|
1/1 |
| 4 Apr 2025 |
Hailey Thompson
2025-0171 · Michael Pemberton
A GP surgery's care navigator lacked clear pathways and triage tools for urgent paediatric allergy referrals, leading to an inappropriate referral and …
|
2/3 |
| 4 Apr 2025 |
Jacqueline Green
2025-0170 · Emma Whitting
The hospital failed to adopt national safety recommendations for paracetamol dosage in low-bodyweight patients, leading to overdose risks due to inadequate prescribing …
|
1/1 |
| 4 Apr 2025 |
Linda Farmer
2025-0169 · Elizabeth Wheeler
The Trust failed to investigate significant care concerns raised by clinicians and neglected its own recommendation for a detailed inquiry, leaving systemic …
|
1/1 |
| 4 Apr 2025 |
Mr YZ
2025-0168 · Hannah Godfrey
Careline operator training and call protocols were inadequate to identify severe injuries in callers with cognitive impairments, specifically failing to elicit critical …
|
1/1 |
| 3 Apr 2025 |
James Masheter
2025-0167 · Kate Bisset
The NHS Pathways system's limited mental health triage options inadequately assess serious mental health crises, leading to low priority categorisation and significant …
|
1/1 |
| 1 Apr 2025 |
Mary Pomeroy
2025-0166 · Nicholas Lane
A hospital's investigation wrongly deemed a fatal patient-on-patient assault unforeseeable, despite ignoring prior violent incidents and failing to implement required enhanced observations …
|
1/1 |
| 31 Mar 2025 |
Abu Rahman
2025-0165 · Harry Lambert
Hospital staff experienced frequent Naloxone shortages leading to delayed administration and demonstrated limited awareness of opioid toxicity risks in patients with kidney …
|
1/1 |