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 |
|---|---|---|
| 17 Mar 2025 |
Darren Turner
2025-0144 · Sean Horstead
Multiple serious failures in care, management, and treatment provided by the Essex Partnership NHS Foundation Trust amounted to neglect, contributing to the …
|
1/1 |
| 14 Mar 2025 |
William Radford
2025-0143 · Penelope Schofield
Inexperienced young drivers, recently passing their test, face increased accident risk when carrying young passengers, highlighting a concern about current regulations.
|
1/1 |
| 14 Mar 2025 |
Alexander Eastwood
2025-0142 · Michael Pemberton
There is a lack of guidance and regulation for children's contact sports, particularly for unofficial matches, leading to an absence of minimum …
|
1/1 |
| 12 Mar 2025 |
Barry Myers
2025-0141 · Lisa Milner
Insufficient funding prevents the provision of urgent mechanical thrombectomy services between 4 pm and 8 am at University Hospitals Sussex NHS Foundation …
|
2/2 |
| 2 Jan 2025 |
James Keen
2025-0140 · Lydia Brown
Untrained support workers at supported accommodation conducted physical health checks without understanding results or their implications, leading to unreliable information and a …
|
1/1 |
| 12 Mar 2025 |
Rhiannon Williams
2025-0139 · Kirsten Heaven
Online suicide forums and social media platforms provided information on self-harm and misleading professionals, raising concerns about the adequacy of The Online …
|
2/2 |
| 11 Mar 2025 |
Allan Taylor
2025-0138 · David Place
Level 2 EICO observation guidelines requiring a nurse to be within sight or sound were not met, as the patient's side room …
|
1/1 |
| 11 Mar 2025 |
Marta Vento
2025-0137 · Rachael Griffin
No formal process exists for prisons to share critical in-prison behavioural and mental health information with sentencing courts. Additionally, national guidance is …
|
5/5 |
| 11 Mar 2025 |
Luke Barnes
2025-0136 · Susan Ridge
Probation staff lack access to specialist medical reports and adequate training on neurodiverse conditions, hindering effective supervision. A loophole also prevents unactioned …
|
1/1 |
| 28 Nov 2024 |
Raymond Reid
2025-0135 · Philip Spinney
Hospital care failures led to sepsis from pressure sores, a UTI, and pneumonia. Concerns include inadequate skin checks, risk assessments, malnutrition screening, …
|
1/1 |
| 11 Mar 2025 |
Christopher Bradbury
2025-0134 · Emma Serrano
A national lack of knowledge and guidelines for Severe Invasive Soft Tissue Infections, combined with ineffective training and an absence of an …
|
2/2 |
| 11 Mar 2025 |
Sean Higgins
2025-0133 · Patricia Harding
Officers chairing ACCT reviews at HMP Rochester failed to read all relevant documentation, leading to inaccurate risk assessments, and some did not …
|
1/1 |
| 30 Jan 2025 |
Liam Allan
2025-0132 · Anton Van Dellen
Inadequate visibility of riverside buoyancy aids and slow, telephone-based police-to-fire service communication create critical delays in emergency response, increasing drowning risks.
|
5/18 |
| 6 Mar 2025 |
John McLoughlin
2025-0131 · Gareth Jones
Peer Support for pilots is inadequate for severe mental health issues and suicidal thoughts, highlighting a lack of robust mental health support …
|
1/2 |
| 6 Mar 2025 |
Andrea Mann
2025-0130 · Angela Brocklehurst
|
1/1 |
| 6 Mar 2025 |
Arsalan Baig
2025-0129 · Angela Brocklehurst
Inadequate street lighting and missing traffic warning signs at a sharp turn towards a wall significantly contributed to a fatal road accident.
|
1/1 |
| 6 Mar 2025 |
Mohammed Khan
2025-0128 · Angela Brocklehurst
Insufficient street lighting and a lack of warning signs at a poorly marked 90-degree turn and dead-end contributed to a fatal road …
|
1/1 |
| 7 Mar 2025 |
Jean Pike
2025-0127 · Kirsten Heaven
Discharge decisions were made without essential multi-disciplinary meetings or consulting care coordinators, despite clear warnings of high suicide risk, indicating a systemic …
|
1/1 |
| 6 Mar 2025 |
Annette Lewis
2025-0126 · Kerrie Burge
Delays in implementing a "Failed Discharge" policy mean patients are not being appropriately referred for specialist review, increasing risks of re-attendance and …
|
1/1 |
| 6 Mar 2025 |
Raymond Jennings
2025-0125 · Steve Eccleston
The care home failed to promptly obtain prescribed antibiotics or seek medical care for a deteriorating resident, and could not demonstrate improved …
|
1/1 |