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 |
|---|---|---|
| 14 Jan 2025 |
Anugrah Abraham
2025-0024 · Joanne Kearsley
Police occupational health lacks specialist mental health nurses and post-death investigation for learning. Protocols are unclear for officers disclosing suicidal thoughts, and …
|
2/3 |
| 13 Jan 2025 |
Joseph Walsh
2025-0023 · M.D. Fleming
There are no legal restrictions on newly qualified drivers carrying multiple young passengers, which increases collision risk and warrants a review of …
|
1/1 |
| 13 Jan 2025 |
Tobias Barraclough
2025-0022 · M.D. Fleming
There are no legal restrictions on newly qualified drivers carrying multiple young passengers, which increases collision risk and warrants a review of …
|
1/1 |
| 13 Jan 2025 |
Angela Carney
2025-0021 · M.D. Fleming
Many mobility scooters, especially older models, lack a crucial secondary hand brake system, creating significant safety risks for riders and the public. …
|
2/2 |
| 13 Jan 2025 |
Diane Poole
2025-0020 · Andre Rebello
A faulty emergency exit door, combined with staff's lack of awareness, inadequate alarm checks, and poor shift handover procedures, created significant safety …
|
1/1 |
| 13 Jan 2025 |
Aarav Chopra
2025-0019 · Louise Hunt
Lack of guidance for immunocompromised patient antibiotics, unclear trainee competence, and poor consent processes were evident. Inadequate learning from deaths and fragmented …
|
2/2 |
| 10 Jan 2025 |
Jan Raciborski
2025-0018 · Robert Simpson
The consistent failure to document risk assessments in contact records hinders information sharing, impedes investigations into deaths, and risks obscuring future threats …
|
1/1 |
| 10 Jan 2025 |
Eden Street
2025-0017 · Paul Marks
Information from parents of autistic children via a helpline is not fed into weekly audit meetings, risking critical updates on deteriorating neurodiverse …
|
1/1 |
| 10 Jan 2025 |
Ava Hodgkinson
2025-0016 · Christopher Long
Current pharmacy restrictions prevent pharmacists from issuing medication in a different strength, even if the correct dosage could be administered, causing dangerous …
|
1/1 |
| 10 Jan 2025 |
Mark-Anthony Summersett
2025-0015 · Joseph Turner
A critical lack of information sharing and communication across agencies, compounded by emergency department triage delays, prevented accurate risk assessment and timely …
|
1/1 |
| 10 Jan 2025 |
Joshua Forsdyke
2025-0014 · Melanie Lee
Ketamine was easily and openly available to students, with drug dealing occurring freely within and between university student halls of residence.
|
2/2 |
| 9 Jan 2025 |
Anthony Paine
2025-0013 · Nicholas Graham
The 30 mph speed limit on A361 North Bar Street is potentially too high. A road rise obscures the pedestrian crossing, increasing …
|
1/1 |
| 9 Jan 2025 |
John Liddle
2025-0012 · Georgina Nolan
A 40 mph speed limit on a residential road with bends, junctions, and a history of collisions is unsafe and requires permanent …
|
1/1 |
| 9 Jan 2025 |
Maria Simpson
2025-0011 · Roland Wooderson
GPs lack a uniform national electronic patient record system, causing delays in record transfer and fragmented storage of historic documents, making quick …
|
1/1 |
| 18 Dec 2024 |
Sylvia Savage
2025-0010 · James Thompson
The care home exhibited inadequate fall reporting, ineffective patient monitoring, reliance on family for medical intervention post-fall, and poor, unsecured record-keeping, hindering …
|
1/1 |
| 7 Jan 2025 |
Sheila Nicholls
2025-0009 · Michael Walsh
The care home had deficient policy management, poor staff understanding, and inadequate emergency response training. Internal investigations into adverse incidents were insufficient …
|
1/1 |
| 8 Jan 2025 |
Matthew Brierley
2025-0008 · Nicholas Shaw
Excessive delays in police investigations prolong suicide risk for vulnerable individuals on bail. Standardised bail conditions and a lack of proactive support …
|
4/3 |
| 7 Jan 2025 |
Thomas Kingston
2025-0007 · Katy Skerrett
There are concerns about adequate communication of suicide risks associated with SSRI medications and the appropriateness of continuing or switching them when …
|
3/3 |
| 2 Jan 2025 |
Alexandra Roberts
2025-0006 · Charlotte Keighley
The minimum prescribed insulin amount was excessively high (300 units), enabling a large overdose, when a smaller amount would have been preferred …
|
1/1 |
| 2 Jan 2025 |
Joseph Forbes Black
2025-0005 · Ian Potter
Naloxone kits are not widely available to drug users, especially those not engaged with substance misuse services, despite the increased risk from …
|
2/2 |