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 42 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
21 Feb 2025	Paul Dunne 2025-0104 · Andrew Harris Mental health professionals exhibited significant gaps in risk assessment judgment, mental health staff failed to follow A&E policies, and incompatible electronic record …	London South London	Care Quality Commission Department of Health and Social … NHS England Oxleas NHS Foundation Trust	2/4
21 Feb 2025	Ann Cotgrove 2025-0103 · John Gittins There was an absence of formal documented processes and record-keeping for inter-hospital referrals, discussions, and the subsequent advice and actions taken.	Wales North Wales (East and Central)	Betsi Cadwaladr University Health Board Ysbyty Gwynedd	1/2
20 Feb 2025	Duncan Holloway 2025-0102 · Mary Hassell Psychotherapy lacked minimum standards for note-keeping and training in suicidality management or emergency police contact. There were also concerns about uncoordinated care …	London Inner North London	British Association for Counselling and … North London NHS Foundation Trust	2/2
21 Feb 2025	Lady Lola Crouch 2025-0101 · Sonia Hayes The patient was not informed of potential malignancy findings from a CT scan, leading to missed follow-up. Additionally, insufficient medical staffing caused …	East of England Essex	Mid & South Essex NHS …	1/1
20 Feb 2025	Paul Collingridge 2025-0100 · Sonia Hayes Roadworks safety procedures have flaws regarding distance calculations, inconsistent road markings, and a lack of requirement to report fatalities on permit applications, …	East of England Essex	Affinity Water Department for Transport Essex County Council Hatton Traffic Management	4/4
18 Feb 2025	Ronald Bainborough 2025-0099 · Sarah Bourke Protracted 20-day timescales for obtaining and executing Mental Health Act warrants, due to limited court availability and police delays, expose individuals to …	London Inner North London	Metropolitan Police Ministry of Justice	2/2
18 Feb 2025	Zahra Mohamed 2025-0098 · Sarah Bourke Significant 2-week delays in obtaining and executing Mental Health Act warrants persist due to court and police scheduling issues, increasing the risk …	London Inner North London	Metropolitan Police Ministry of Justice	2/2
20 Feb 2025	Hayley Beavington 2025-0097 · Edwin Buckett A crisis house wrongly denied admission to a high-risk suicidal patient due to restrictive criteria. The consultant failed to guide the junior …	London Inner North London	North London NHS Foundation Trust	1/1
19 Feb 2025	Margaret Rodgers 2025-0096 · Susan Ridge Pressure ulcer risk assessments are not yet consistently embedded in the Emergency Department, and the ward continues to experience insufficient nursing staff …	South East Surrey	Surrey and Sussex Healthcare NHS …	1/1
19 Feb 2025	Philip Unwin 2025-0095 · Daniel Howe Medical teams failed to timely escalate care for a deteriorating patient, and the Emergency Department resuscitation area remains understaffed, not complying with …	West Midlands Staffordshire and Stoke on Trent	NHS England Royal Stoke University Hospital	2/2
19 Feb 2025	Kenneth Clayton 2025-0094 · Alison Mutch Prolonged Emergency Department waits in unsuitable environments for high falls-risk patients, driven by ward bed shortages and delayed discharges, highlight inconsistent national …	North West Manchester South	Department of Health and Social …	1/1
17 Feb 2025	Carl Eastman 2025-0093 · Ian Potter There were significant delays in conducting critical CT scans, widespread communication failures, poor record-keeping, and a lack of professional curiosity among staff, …	London Inner North London	Royal Free London NHS Foundation …	1/1
18 Feb 2025	Jeffrey Tyler 2025-0092 · Caroline Saunders Ambulance call handlers failed to clinically override the dispatch system's categorization, maintaining a low priority despite clear evidence of the patient's severe, …	Wales Gwent	Minister for Health (Wales) Welsh Parliament	1/2
17 Feb 2025	Diana Fairweather-Purkis 2025-0091 · Paul Appleton Insufficient ambulance availability leads to delayed patient attendance, exacerbated by excessive handover delays at hospitals, hindering ambulance crew release and further impacting …	North East Teesside and Hartlepool	DEPARTMENT OF HEALTH NHS ENGLAND NHS NORTH EAST AND NORTH …	3/3
12 Dec 2024	Jean Mullen 2025-0090 · N J Mundy Social care dismissed family concerns regarding the deceased's ability to manage stairs and live safely at home post-fall, relying on an inadequate …	Yorkshire and the Humber South Yorkshire East	Doncaster Council	1/1
17 Feb 2025	David Bennett 2025-0089 · Sonia Hayes Mental health crisis and acute care staff lacked access to crucial patient records, leading to inadequate information sharing and failures in escalating …	East of England Essex	Essex Partnership University NHS Trust Mid & South Essex NHS …	2/2
17 Feb 2025	Kevin O’Reilly 2025-0088 · Emma Serrano All lanes open motorways present a significant hazard due to insufficient emergency stopping areas spaced 1.6 miles apart and a lack of …	West Midlands Staffordshire	Highways England	1/1
14 Feb 2025	Jason Myles 2025-0087 · Paul Marks A dangerous road known as "suicide hill" has a history of fatal collisions due to a sharp turn and topography; improved signage …	Yorkshire and the Humber City of Kingston Upon Hull and …	ERYC Highways Department	1/1
10 Feb 2025	Yahya Hayat 2025-0086 · Peter Merchant Changes in paediatric training removed compulsory direct observed training for neonatal intubation, increasing reliance on consultants and reducing future general paediatricians' experience …	North West Greater Manchester South	Royal College of Paediatrics and …	1/1
7 Feb 2025	Ian Jones 2025-0085 · Gavin Knox The easy accessibility of electric motors and parts enables the conversion of pedal bicycles into high-powered, throttle-controlled scooters, posing dangers to both …	Wales South Wales Central	Department for Transport Welsh Government	1/2