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 |
|---|---|---|
| 6 Mar 2025 |
Henok Gebrsslasie
2025-0124 · Delroy Henry
Despite a known risk of ligature points on patient bedroom doors and identification of door top alarms as a solution, these crucial …
|
1/1 |
| 21 Feb 2025 |
Luke Worrell
2025-0123 · Andrew Harris
Clinical staff lacked awareness of potentially fatal Clozapine side effects and inappropriately used a community treatment order when a higher level of …
|
4/5 |
| 4 Mar 2025 |
Jack Shields
2025-0122 · David Place
An ambulance crew failed to recognise a patient's critical deterioration into cardiogenic shock and incorrectly prioritised their backup request, resulting in a …
|
1/1 |
| 4 Mar 2025 |
Chloe Burgess
2025-0121 · Nicholas Walker
The severe interaction between amitriptyline, paroxetine, and ivabradine is poorly understood, not flagged by prescribing software, and prescribers lack full awareness, posing …
|
2/2 |
| 4 Mar 2025 |
Robert Evans
2025-0120 · David Lewis
A lack of guidance and power prevents police officers from ensuring medical attention for individuals suspected of swallowing drugs during a street …
|
2/2 |
| 4 Mar 2025 |
Matthew Lynch
2025-0119 · Louise Hunt
The internal investigation was inadequate, and barriers exist to proper Mental Health Act assessments. There's poor information sharing between agencies regarding residents, …
|
2/3 |
| 4 Mar 2025 |
Alfie Lawless
2025-0118 · Chris Morris
Greater Manchester Police significantly delayed classifying a death as a "Death or Serious Injury" incident, raising concerns about the quality of their …
|
1/1 |
| 3 Mar 2025 |
Javed Iqbal
2025-0117 · James Bennett
Care home staff failed to recognise and appropriately act on serious mental health deterioration, made inaccurate records, and did not follow GP …
|
1/1 |
| 10 Feb 2025 |
Anne Towlson
2025-0116 · Isobel Thistlethwaite
Concerns arise from the inability to obtain medical records or information from the Turkish hospital regarding fitness for surgery, alongside inadequate post-operative …
|
1/1 |
| 28 Feb 2025 |
Lachlan Campbell
2025-0115 · Andrew Cox
Critical ambulance response delays, caused by extensive hospital handover times, prevented timely conveyance of a patient to hospital, which an expert stated …
|
1/1 |
| 28 Feb 2025 |
Lachlan Campbell
2025-0114 · Andrew Cox
Poor information sharing between ambulance service and police, including incorrect call status and police not being given ETAs or asked about scene …
|
2/2 |
| 28 Feb 2025 |
William Green
2025-0113 · Heath Westerman
The hospital lacks a system to provide written information or counselling to patients, or their families, about new drug side-effects, potential complications, …
|
2/2 |
| 28 Feb 2025 |
June Phillips
2025-0112 · Louise Hunt
Inaccurate care home records, failure to update falls risk assessments, and an inadequate post-falls investigation indicate a failure to learn from incidents …
|
1/1 |
| 27 Feb 2025 |
Philip Jones
2025-0111 · Richard Middleton
Denture adhesive gel poses an unadvertised choking hazard, particularly for vulnerable elderly individuals, and lacks essential warnings on its packaging or leaflet …
|
2/2 |
| 27 Feb 2025 |
Joshua Leatham-Prosser
2025-0110 · Richard Middleton
Ketamine is easily accessible, perceived as less harmful by teenagers, and its highly addictive nature causes severe, irreversible bladder damage (ketamine cystitis), …
|
1/1 |
| 25 Feb 2025 |
Khadija Kerri
2025-0109 · Louise Slater
The hospital lacked a clear policy for disseminating addendum radiology reports from external providers to the treating clinical team, causing critical delays …
|
1/1 |
| 20 Feb 2025 |
Janet Scott
2025-0108 · Robert Cohen
The "safeguarding is everyone's responsibility" message is not fully embedded, with agencies potentially failing to make referrals if they believe others are …
|
1/1 |
| 24 Feb 2025 |
Pamela Marking
2025-0107 · Karen Henderson
Misleading titles and public misunderstanding of Physician Associate roles, coupled with inadequate national guidelines and direct supervision, risk patient safety through PAs …
|
8/10 |
| 24 Feb 2025 |
Isaiah Olugosi
2025-0106 · Richard Furniss
A critical buzzer/intercom system in the prison has been inoperable for years, preventing emergency warnings, and authorities are unwilling to repair or …
|
1/1 |
| 24 Feb 2025 |
Amy Padley
2025-0105 · Kirsten Heaven
Mental health services prioritize addiction treatment over mental health support, lack guidance for staff on managing co-occurring conditions, and are reluctant to …
|
1/1 |