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 Feb 2025 |
Katrina Insleay
2025-0084 · James Puzey
The absence of a formal handover system and shared record access between hospital and Neighbourhood Teams for pressure sore patients creates a …
|
1/2 |
| 12 Feb 2025 |
Gary James
2025-0083 · Clare Bailey
The workplace exhibited a severe lack of risk assessment, inadequate training, unsafe equipment, and inappropriate working conditions, compounded by a culture that …
|
1/1 |
| 11 Feb 2025 |
John Tompkins
2025-0082 · R Brittain
The Trust conducted a limited internal review of the circumstances, failing to consider or apply the NatSSIPS2 standards during procedures or in …
|
1/1 |
| 11 Feb 2025 |
Nicholas J’Dourou
2025-0081 · R Brittain
A lack of national guidance for psychiatric medication cross-titration leads to inconsistent and potentially unsafe practices, while the discontinuation of electronic patient …
|
1/1 |
| 17 Dec 2025 |
Anthony Binfield
2025-0080 · Laurinda Bower
A dangerous prison culture of delaying cell entry when observation panels are obscured, assuming privacy rather than self-harm risk, persists despite repeated …
|
1/1 |
| 7 Feb 2025 |
Anthony Binfield, David Richards and Rolandas Karbauskas
2025-0079 · Laurinda Bower
Inadequate recruitment, retention, and training of prison and healthcare staff led to severe understaffing, restricted services, and fundamental failures in prisoner welfare, …
|
5/5 |
| 5 Feb 2025 |
Leslie Hurwood
2025-0078 · Jonathan Dixey
Hospital nurses are incorrectly administering insulin after meals, reducing its effectiveness and causing hypoglycaemic episodes, indicating insufficient training adherence and potential staffing …
|
1/1 |
| 7 Feb 2025 |
Amelia Ridout
2025-0077 · Elizabeth Gray
A lack of national guidelines and standardized procedures for bone marrow aspirate and trephine biopsy, coupled with no database for recording outcomes, …
|
3/3 |
| 7 Feb 2025 |
Kenton Beasley
2025-0076 · Joseph Turner
A protracted and frustrating DVLA licence renewal process, characterized by communication failures, incorrect information, and lack of vulnerable customer support, significantly exacerbated …
|
1/1 |
| 7 Feb 2025 |
Dafydd Craven-Jones, Dafydd Jones and Sophie Bates
2025-0075 · Kelly Dixon
Multiple fatal collisions on the B5012 Cannock Road highlight concerns about inadequate signage prominence and missing road markings on the approach to …
|
0/1 |
| 6 Feb 2025 |
Jane Bennett
2025-0074 · Anne Pember
The junction of St Johns Road, Tiffield and the A43 Northamptonshire is dangerously difficult to manoeuvre, posing a high risk of further …
|
1/1 |
| 24 Jan 2025 |
Andrew Heys
2025-0073 · John Pollard
Out-of-hours GPs lack training on internal protocols and accessing patient records, compounded by fragmented NHS IT systems that prevent health professionals from …
|
2/2 |
| 4 Feb 2025 |
Carla James
2025-0072 · Joanne Kearsley
Products are being imported and sold without adequate warnings about their highly poisonous and toxic nature, posing a serious risk to life.
|
2/3 |
| 4 Feb 2025 |
Dorothy Reid
2025-0071 · Catherine Wood
Persistent hospital bed blocking by discharged patients causes excessive A&E waiting times, deterring critically ill patients from seeking care and increasing the …
|
2/2 |
| 5 Feb 2025 |
Sapphire Bernard
2025-0070 · Penelope Scofield
Critical shortage of psychiatric beds leads to dangerously long waits in unsuitable A&E environments, exacerbating mental health for neurodiverse patients.
|
2/2 |
| 27 Jan 2025 |
William Northcott
2025-0069 · Louise Wiltshire
Disparities in Clozapine monitoring between specialist clinics and GP practices lead to inadequate patient education on side effects, while guidance also underemphasizes …
|
4/4 |
| 13 Dec 2024 |
Jean Langan
2025-0068 · Ian Arrow
The absence of a real-time database for hospital helicopter landing sites and a lack of readily available manager contact details present significant …
|
3/2 |
| 5 Feb 2025 |
Terence Grainger
2025-0067 · Chris Morris
Lack of electronic patient observation systems poses a risk due to potential manual recording errors, miscalculation of NEWS 2 scores, and inability …
|
1/1 |
| 4 Feb 2025 |
Peter Jones
2025-0066 · Mary Hassell
Police station design flaws, including flat-topped telephone hoods and inadequate public reception area oversight, contributed to the death, highlighting safety equipment and …
|
1/1 |
| 5 Feb 2025 |
Simon Harding
2025-0065 · Samantha Marsh
A severe lack of safety protocols at the moto-cross track, including no rider registration, safety briefings, or skill segregation, coupled with inadequate …
|
2/2 |