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.

Response tracker Organisations Advanced search

Keyword

Browse by year

Browse by region

Sort

Reports

6,383 reports · Page 44 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
3 Feb 2025	Wyllow-Raine Swinburn 2025-0064 · Darren Salter Significant delays in connecting 999 calls to Emergency Call Takers and subsequent ambulance response times pose a risk, indicating a need for …	South East Oxfordshire	South Central Ambulance Service	2/1
30 Jan 2025	Graham Whiteley 2025-0063 · Vanessa McKinlay Prolonged ambulance response times are caused by severe hospital handover delays, resulting in significant lost ambulance capacity and ongoing risk to critically …	South West Somerset	South Western Ambulance Service NHS …	1/1
30 Jan 2025	Alex Crook 2025-0062 · John Pollard Critical safety failures include schools breaching statutory swimming lesson duties, inadequate "no swimming" signage at open water, and poor placement of life-saving …	North West Manchester West	Wigan Metropolitan Borough Council	1/1
24 Jan 2025	Cynthia Gilbert 2025-0061 · Vanessa McKinlay Persistent non-adherence to repositioning care plans for a high-risk patient, despite repeated interventions, led to severe pressure ulcer deterioration, raising concerns about …	South West Somerset	Somerset NHS Foundation Trust	1/1
3 Feb 2025	Afolabi Ojerinde 2025-0060 · Zak Golombeck Petrol stations lack adequate controls and guidance to ensure compliance with regulations regarding dispensing petrol, failing to prevent unsafe access to fuel.	North West Manchester City	Association for Petroleum and Explosives … Department for Work and Pensions Energy Institute Petroleum Enforcement Liaison Group	2/4
23 Oct 2024	Jean Thomas 2025-0059 · Caroline Saunders Critical fluid balance monitoring for a patient with severe cardiovascular and renal issues, complicated by sepsis, was entirely neglected by both nursing …	Wales Gwent	Aneurin Bevan University Health Board	1/1
12 Dec 2024	Huw Erasmus 2025-0058 · Caroline Saunders There was a lack of documented post-leave assessments for a patient with a known risk of ingesting vegetation, alongside staff confusion regarding …	Wales Gwent	Elysium Healthcare	1/1
31 Jan 2025	Aeran Taylor 2025-0057 · Joseph Turner Deficient mental health assessments at military discharge, lack of inquiry into drug use linked to potential PTSD, and insufficient long-term rehabilitation options …	South East West Sussex, Brighton and Hove	Ministry of Defence	1/1
25 Sep 2018	Caitlin Huddleston and Skye Mitchell 2025-0056 · Robert Chapman Inexperienced young drivers carrying multiple passengers face increased distraction and risk, highlighting the need for a Graduated Driving Licence Scheme with passenger …	North West Cumbria	Department for Transport	2/1
31 Jan 2025	Kim Robinson 2025-0055 · Nigel Parsley The online prescription system lacks critical safety features, including access to patient records, consent for GP sharing, and suicide screening, enabling unsafe …	East of England Suffolk	Department of Health and Social …	1/1
30 Jan 2025	Shaun Hall 2025-0054 · Anne Pember The Urgent Care and Assessment Team declined a referral despite clear suicide risks, with the decision-maker remaining unidentified and no record of …	East Midlands Northamptonshire	Northamptonshire Healthcare Foundation Trust	1/1
31 Jan 2025	Nicola Owens 2025-0053 · Anita Bhardwaj Persistent ambulance delays are caused by hospital handover backlogs, which stem from a lack of social care packages for discharged patients, severely …	North West Liverpool and Wirral	Department of Health and Social … NHS England & NHS Improvement The Chief Coroner	2/3
31 Jan 2025	Alexander Channing 2025-0052 · Richard T Middleton Systemic failures in mental health care transfer protocols, university staff training, hospital discharge planning, and patient information sharing policies created significant risks …	South West Dorset	Arts University Bournemouth Devon Partnership NHS Trust Dorset Healthcare NHS Foundation Trust	3/3
30 Jan 2025	James Siddons 2025-0051 · Liliane Field A care home's flawed internal investigation into a patient fracture, lacking detailed guidance and staff training, prevented learning from the incident and …	London London Inner (South)	London Borough of Bromley Mills Family Ltd	2/2
29 Jan 2025	Carla Smith 2025-0050 · Samantha Goward Excessively long hospital waiting lists for urgent and routine referrals, coupled with a lack of patient monitoring, risk significant deterioration and loss …	East of England Norfolk	Department of Health and Social …	1/1
29 Jan 2025	Naomi Suleyman 2025-0049 · Liliane Field Inaccurate discharge passports, inadequate screening, missed welfare checks, and delayed community care referrals led to an unsafe patient discharge, compounded by fragmented …	London London Inner (South)	Lewisham and Greenwich NHS Trust London Borough of Lambeth London Borough of Lewisham	1/3
24 Jan 2025	Charlie Marriage 2025-0048 · Xavier Mooyaart Patients with "cliff-edge conditions" are not identified within the health system, leading to inadequate patient awareness of risks, poor urgent care recognition, …	London Inner South London	NHS England	1/1
3 Dec 2024	Paul Gobell 2025-0047 · Simon Burge There is no policy for welfare checks when initial interviews are missed, and changes in cell sharing risk are not promptly communicated …	East Midlands Nottingham City and Nottinghamshire	HM Inspectorate of Prisons Ministry of Justice	2/2
27 Jan 2025	William Bissett 2025-0046 · Nicholas Rheinberg Severe systemic failures in release planning for a vulnerable, elderly prisoner, including delayed engagement, inadequate accommodation arrangements, and insufficient emotional support, resulted …	North West Liverpool and Wirral	HMPPS HMP Wymott	2/2
20 Jan 2025	REDACTED 2025-0045 · Ian Potter Student accommodation staff caused significant delays in initiating and physically conducting a welfare check, and showed reluctance to fully enter the room, …	London Inner North London	Unite Group plc	1/1