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 |
|---|---|---|
| 24 Jan 2025 |
Neville McKenzie
2025-0044 · Emma Brown
Care homes lack widespread knowledge and regulatory requirement for anti-choking devices, even for high-risk residents, creating an avoidable risk of deaths from …
|
2/2 |
| 23 Jan 2025 |
Brian Kneale
2025-0043 · Alan Wilson
Ineffective and inaccurate monitoring of fluid balances hinders clinicians' decision-making and prevents hospital reviews from learning correct lessons.
|
1/1 |
| 17 Jan 2025 |
Donald Mitchell
2025-0042 · Patricia Morgan
A dangerous 5.75-mile stretch of the A48 road, with varying speeds and no dedicated cyclist safety infrastructure, has a high number of …
|
1/2 |
| 23 Dec 2024 |
David Lodge
2025-0041 · Edward Steele
The emergency department failed to accurately assess pain in a non-verbal patient, conduct basic examinations for pneumonia, and appropriately escalate high NEWS2 …
|
3/3 |
| 22 Jan 2025 |
Joanna Kowalczyk
2025-0040 · Leila Benyounes
A paramedic lacked crucial stroke symptom training, and chiropractors do not routinely obtain medical records before assessment, particularly after recent hospital visits, …
|
4/2 |
| 22 Jan 2025 |
Fahmida Khanam
2025-0039 · Kevin McLoughlin
A doctor treated a close relative, breaching the cardinal principle of medical ethics.
|
2/1 |
| 22 Jan 2025 |
Nathan Shepherd
2025-0038 · Alison Mutch
The Probation Service lacked policy and training for barricading incidents, approved premises had easily movable furniture and ligature points, agency staff CPR …
|
1/1 |
| 21 Jan 2025 |
Reginald Smith
2025-0037 · Richard Middleton
A potentially deformed surgical jig, lacking quality control and auditing, may have caused incorrect hip screw insertion, compounded by the loss of …
|
2/2 |
| 21 Jan 2025 |
Paul Williams
2025-0036 · Alison Mutch
Homelessness, forced family separation, and prolonged waiting times for public housing severely impacted mental health, contributing to the deceased's deteriorating condition.
|
1/1 |
| 21 Jan 2025 |
Carl Butler and Sean Brett
2025-0035 · John Gittins
Cheshire Police had confused report management with no officer acknowledgement system and significant delays in delivering critical ANPR/Vehicle Finder system training to …
|
1/1 |
| 20 Jan 2025 |
Harry Southern
2025-0034 · Gareth Jones
Suicide prevention information is inadequately provided and often inaccessible for young people, with contact numbers unmonitored or unsuitable for those with disabilities, …
|
1/1 |
| 17 Jan 2025 |
Vauna Leeming
2025-0033 · David Reid
Nurses, including agency staff, consistently failed to document vital anticoagulation and compression stocking administration, indicating insufficient awareness of professional duties and reporting …
|
1/1 |
| 17 Jan 2025 |
Jackson Yeow
2025-0032 · David Regan
Routine corridor care in the emergency department impedes clinical assessment, delays ambulance handovers, and normalizes unsafe practices due to significant delays in …
|
1/1 |
| 30 Dec 2024 |
Ian Harris
2025-0031 · John Ellery
The HGV licence medical process allows drivers to use independent GPs without access to full medical history, enabling them to hide disqualifying …
|
1/1 |
| 30 Dec 2024 |
Denise Johnson
2025-0030 · Daniel Sharpstone
The hospital had insufficient timely feedback for practitioners on ERCP complications, poor communication with families, and unclear consultant cover for unexpected leave, …
|
1/1 |
| 16 Jan 2025 |
Alexander Thomas
2025-0029 · Adrian Farrow
A pedestrian walkway beneath the M56 motorway provides easy, unguarded access to the eastbound carriageway's hard shoulder via a ramp and fixed …
|
1/1 |
| 15 Jan 2025 |
Sheila Wexler
2025-0028 · Ian Potter
A nationwide medical equipment supplier caused significant delays and provided defective equipment, including an incorrect pump for a turning system, leading to …
|
2/2 |
| 15 Jan 2025 |
Tammy Milward
2025-0027 · Susan Ridge
Incompatible electronic record systems and poor co-location hinder coordination and communication between GP practices and mental health services, placing patients at risk …
|
2/2 |
| 15 Jan 2025 |
Robert McGowan
2025-0026 · Chris Morris
Cultural, structural, and systemic barriers prevented a patient with Autism and complex mental health needs from receiving adequate physical health treatment, resulting …
|
1/1 |
| 13 Jan 2025 |
June Liddell
2025-0025 · Joanne Andrews
Critical error messages and equipment defect indicators are not documented in user instructions or known to staff. Machine maintenance procedures also fail …
|
2/1 |