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 |
|---|---|---|
| 28 Mar 2025 |
Derrick Tully
2025-0164 · Melanie Lee
Failures included unsuitable housing without a key safe, an inappropriate reablement package for a cognitively impaired patient, and neglected recording/escalation of patient …
|
3/3 |
| 27 Mar 2025 |
William Hewes
2025-0163 · Mary Hassell
A patient experienced significant delays receiving critical treatment despite immediate recognition of their life-threatening condition. The hospital's subsequent learning from this event …
|
1/1 |
| 26 Mar 2025 |
Derek Cole
2025-0162 · Samantha Goward
The GP practice failed to communicate abnormal test results to specialists or ensure follow-up, and lacked a robust system for learning from …
|
1/1 |
| 24 Mar 2025 |
Claire Driver
2025-0161 · Tanya Rawden
Mental health teams exhibited inadequate assertive engagement and poor police liaison for a deteriorating patient, compounded by a lack of mandatory staff …
|
1/1 |
| 25 Mar 2025 |
Oladeji Omishore
2025-0160 · Fiona J Wilcox
Police dispatch failed to relay crucial mental health information to responding officers via airwaves, leading to an initial lack of consideration for …
|
1/2 |
| 25 Mar 2025 |
Peter Konitzer
2025-0159 · Nicholas Rheinberg
HSE website guidance for volunteers is insufficient, failing to emphasize written risk assessments for construction work or provide a comprehensive guide on …
|
1/1 |
| 9 Jan 2025 |
David Tighe
2025-0158 · Michael Walsh
The trust lacked a specific Ryles tube policy, leading to inconsistent care and documentation. A subsequent review was too narrow, missing critical …
|
1/1 |
| 24 Mar 2025 |
Thomas Glover
2025-0157 · Nigel Parsley
NHS England clinicians often lack awareness of the critical distinction between hiatus hernia types, leading to insufficient vigilance for higher-risk para-oesophageal cases …
|
2/2 |
| 24 Mar 2025 |
Imogen Nunn
2025-0156 · Penelope Schofield
A severe shortage of British Sign Language interpreters is hindering urgent mental health crisis assessments and delaying judicial proceedings for deaf patients …
|
3/3 |
| 21 Mar 2025 |
Ida Lock
2025-0155 · James Adeley
The Trust suffers from a deep-seated lack of candour, transparency, and deficient clinical governance, resulting in a failure to learn from past …
|
4/4 |
| 19 Mar 2025 |
William Grieve
2025-0154 · Emma Serrano
Critical suicide risk assessments were flawed because different healthcare teams used incompatible electronic systems, preventing access to complete patient notes. Unaddressed staff …
|
2/3 |
| 19 Mar 2025 |
Leanne Carroll
2025-0153 · Kate Robertson
The Perinatal Mental Health Service suffers from insufficient awareness among health professionals, inadequate staffing levels, and a lack of documented decisions and …
|
1/1 |
| 18 Mar 2025 |
Alonzo Wood
2025-0152 · Joanne Andrews
Clinicians lack clear guidance on managing abnormal antenatal CTGs, specifically regarding decisions and timing of delivery, leading to inconsistent reliance on individual …
|
2/2 |
| 19 Mar 2025 |
Winnie Harrop
2025-0151 · Jyoti Gill
Inadequate guidance exists for discharging overly sedated patients with new oxygen needs from hospital to a non-nursing care home, compounded by missing …
|
2/2 |
| 19 Mar 2025 |
Sheridan Pickett
2025-0150 · Jyoti Gill
No specific coroner's concerns regarding systemic issues or risks to prevent future deaths were identified in the provided text.
|
1/1 |
| 18 Mar 2025 |
Renate Mark
2025-0149 · Andrew Hetherington
The trust's falls investigation was flawed due to reliance on incorrect witness accounts, and a misunderstanding of 'line of sight' observation for …
|
1/1 |
| 11 Mar 2025 |
Nicholas Gedge
2025-0148 · Oliver Longstaff
A significant delay in commencing CPR occurred due to a lack of shared understanding of its urgency and an uncoordinated response among …
|
2/2 |
| 4 Mar 2025 |
Mark Fernandez
2025-0147 · Joanne Kearsley
Inadequate information was provided in a specialist referral, the hospital passport was unused, and a best interest decision failed to incorporate crucial …
|
4/3 |
| 17 Mar 2025 |
Billie Wicks
2025-0146 · Mary Hassell
The emergency department was understaffed, leading to missed vital observations and delayed antibiotic administration. Inadequate staff training on adult onset asthma and …
|
3/3 |
| 17 Mar 2025 |
Colin Colley
2025-0145 · Rachel Knight
Nursing staff and healthcare workers at St David’s hospital lack confidence and adequate training in falls risk assessments, enhanced supervision, and proper …
|
1/1 |