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 4 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
20 Apr 2026	Paul Hutchinson 2026-0223 · Richard Furniss Fire safety regulations may not specifically address individual flats within Extra Care Supported Accommodation (ECSA), potentially leaving vulnerable residents at risk due …	London West London	Care Quality Commission Local Government Association Minister for Housing Communities and … National Fire Chiefs Council	0/4
15 Apr 2026	Lisa Taylor-Penny 2026-0220 · Elizabeth Wheeler The rigid implementation of "Right care right person" (RCRP) may limit call handlers' ability to escalate calls to senior staff, even when …	North West Cheshire	Cheshire Police	1/1
4 Jan 2026	Lajos Mandrik 2026-0219 · Richard Furniss Observations on Ellis Ward may not be carried out in accordance with Trust policy, with staff not always attempting to engage with …	London West London	South West London and St …	2/1
14 Apr 2026	James Stewart 2026-0221 · Robert Cohen Flow Coordinators arranging patient discharges may lack information about patient vulnerabilities, potentially leading to unsuitable arrangements being made.	North West Cumbria	North Cumbria Integrated Care NHS …	1/1
12 Mar 2026	Albert Bellingham 2026-0176 · Andrew Walker There is a need for guidance and training to support doctors working in care homes in an interventional, supervisory role when dealing …	London North London	Department of Health and Social …	2/1
16 Apr 2025	Adam Ankers 2026-0217 · Valerie Charbit Lay people, including ambulance call handlers, may have difficulty understanding the signs of agonal breathing or cardiac arrest.	London West London	Association of Ambulance Chief Executives Cardiac Risk in the Young … Department of Health and Social … Faculty of Sport and Exercise …	12/13
14 Apr 2026	Kiefer Fraser-Phillips 2026-0216 · Louise Hunt Therapeutic observations were not accurately recorded due to Wi-Fi signal issues, and there was no care plan in place to address the …	West Midlands Birmingham and Solihull	Birmingham and Solihull Mental Health …	1/1
14 Apr 2026	Catherine Oliver 2026-0215 · Nicholas Graham Prolonged storage of household items in the main living area created a hazard for an elderly tenant, and there were no clear …	South East Oxfordshire	Sanctuary Housing Association	0/1
14 Apr 2026	Susan Toft 2026-0214 · Andrew Bridgman The detachment of a wheelchair seat cushion after only 9 months raised concerns about the robustness of the attachment method, and a …	North West Manchester South	British Health Trades Association Wheelchair Alliance Wheelchair Accessible Vehicle Converters Association	0/3
10 Apr 2026	Wayne Austin 2026-0213 · Heath Westerman Difficulties locating the appropriate cardiac arrest guidance on the JRCALC app, the inability of paramedics to comply with respiratory arrest guidelines, and …	West Midlands Shropshire, Telford and Wrekin	Joint Royal Colleges Ambulance Liaison … West Midlands Amublance Service	2/2
10 Apr 2026	Garry Mills 2026-0212 · Darren Stewart The coroner raises concerns that the £250 per week allowance for reasonable living expenses under Proceeds of Crime Act Restraint Orders, which …	South East Surrey	Attorney General of England and …	0/1
11 Mar 2026	Peter Campbell 2026-0211 · Mary Hassell Drugs are rife within Pentonville prison, and there was a failure by the prison drug service to provide a meaningful interaction with …	London Inner North London	HM Prison Pentonville HM Prison & Probation Service Phoenix Futures Practice Plus Group	4/4
8 Feb 2022	John Moore 2026-0210 · Sean Horstead EPUT Care Coordinators receive inadequate formal training for their role, leading to failures in record keeping, care plan updates, communication with other …	East of England Essex	Department of Health and Social … Essex Partnership NHS Trust Health Education England NHS England	3/4
1 Apr 2026	Hollie Loraine 2026-0193 · David Place The national NHS pathways telephone triage system provides no specific guidance on whether to maintain telephone contact with a patient expressing suicidal …	North East Sunderland	NHS England	1/1
1 Apr 2026	Colin Foley 2026-0188 · Paul Marks The coroner recommends that the NHS at large should be aware of issues relating to the insertion, maintenance, and documentation of intravenous …	Hull and East Riding	NHS England	1/1
25 Mar 2026	[REDACTED] 2026-0178 · Fiona Wilcox Child death investigation teams may be too easily reassured by well-presented homes, leading to perfunctory scene examinations and lost forensic opportunities.	London Inner West London	College of Policing Haleon UK Trading Limited Metropolis National Crime Agency	0/4
6 Apr 2026	Allan Stevenson 2026-0207 · Nigel Parsley A traffic management plan was incorrectly implemented due to inaccurate map coordinates, leading to improper signage and a road traffic collision; special …	East of England Suffolk	Anglican Water Secretary of State for Transport Suffolk County Council	5/3
12 Feb 2026	Barry Harmer 2026-0203 · Crispin Butler The initial Patient Safety Incident Investigation lacked robustness and did not appear to have been revisited in light of emerging family concerns; …	South East Buckinghamshire	Oxford Health NHS Foundation Trust	0/1
2 Apr 2026	David Abbot 2026-0195 · Darren Stewart Incorrect advice was given to a patient upon discharge from West Suffolk Hospital regarding weight bearing and mobilisation, potentially contributing to the …	East of England Suffolk	West Suffolk NHS Foundation Trust	1/1
8 Apr 2026	Gary Starbuck 2026-0204 · Darren Stewart The coroner expressed concern that patients receiving private care for skin cancers may receive inferior care compared to NHS patients, due to …	South East Surrey	Care Quality Commission Royal College of Surgeons	2/2