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 47 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
2 Jan 2025	Morgan Betchley 2025-0004 · Lisa Milner The mental health Trust lacked policy or guidance for assessing suicide risks posed by fixtures and fittings supplied to acute mental health …	South East West Sussex, Brighton & Hove	NHS England Sussex Partnership NHS Foundation Trust	2/2
2 Jan 2025	Peter Good 2025-0003 · Chris Morris Indications of prolonged neglect, including poor hygiene and infected wounds, prompted a safeguarding alert. However, the nursing home owner failed to investigate …	North West Manchester South	Harbour Healthcare Ltd	1/1
2 Jan 2025	Victor Knowles 2025-0002 · Charlotte Keighley The care home lacked internal investigation mechanisms and a system for learning from deaths, failing to identify missed opportunities or improve care …	North West Cheshire	Henning Hall Nursing Home Springcare Care Homes Ltd	1/2
2 Jan 2025	Gemma Marshall 2025-0001 · Steve Eccleston An outsourced radiologist with insufficient expertise misreported a CT scan, failing to identify a slipped gastric band due to a lack of …	Yorkshire and the Humber West Yorkshire (Western)	NHS England Royal College of Radiologists	2/2
31 Dec 2024	David Crompton 2024-0713 · Kevin McLoughlin The pharmacy repeatedly failed to promptly supply essential anti-epileptic medication, leaving the patient without treatment and lacking clear systems for managing supply …	Yorkshire and the Humber West Yorkshire (Eastern)	General Pharmaceutical Council Midway Pharmacy	2/2
30 Dec 2024	Michael Jervis 2024-0712 · Guy Davies Despite repeated observations indicating sepsis and a need for antibiotics, the sepsis six protocol was not triggered due to staff failure and …	South West Cornwall and Isles of Scilly	Royal Cornwall Hospital Trust	1/1
24 Dec 2024	Paul Taylor 2024-0710 · Nathanael Hartley Suspects interviewed on a voluntary basis for relevant offences do not receive automatic mental health nurse referrals, creating a disparity in access …	East Midlands Nottingham and Nottinghamshire	Nottinghamshire Police	1/1
23 Dec 2024	Nigel Sweet 2024-0711 · Guy Davies A dangerous stretch of the A38 with a high collision rate lacks funding for a proposed average speed camera safety scheme.	South West Cornwall and Isles of Scilly	National Highways	1/1
24 Dec 2024	Daniel Isaacs 2024-0709 · Nathanael Hartley There is no requirement for electric scooter riders to wear helmets, increasing the risk of fatal head injuries in collisions due to …	East Midlands Nottingham and Nottinghamshire	Department for Transport	1/1
23 Dec 2024	William Hare 2024-0708 · Rebecca Mundy Significant and systemic delays occurred in diagnosis, biopsy, MDT reviews, and treatment due to fragmented systems, poor inter-hospital coordination, and procedural errors.	East of England Essex	Mid and South Essex NHS …	1/1
13 Dec 2024	James Alderman 2024-0707 · Lydia Brown There is a critical lack of clear public and professional safety guidance regarding the positioning and use of baby carriers/slings, particularly for …	London West London	BSI Group Department of Health and Social … NHS England Office for Product Safety and …	4/4
20 Dec 2024	Edith Pye 2024-0706 · David Reid The care home had ambiguous care plans, staff routinely failed to follow safety protocols, and handover documents were deficient and unaudited, indicating …	West Midlands Worcestershire	Care UK Ltd	1/1
20 Dec 2024	Eleanor Curley-Bennett 2024-0705 · Emma Serrano There was a critical lack of availability of essential medical equipment and adrenaline, which severely compromised the ability to provide emergency care.	West Midlands Staffordshire	Festimed	1/1
20 Dec 2024	Susan Karakoc 2024-0702 · Amanda Bewley Search engines readily return websites selling addictive prescription medications, indicating a failure in monitoring online supply chains and detecting criminal financial enterprises.	East Midlands Nottingham and Nottinghamshire	Department for Science, Innovation and … Department of Health and Social … Minister of State for Prisons, … Financial Conduct Authority	3/5
20 Dec 2024	Haydar Jefferies 2024-0702-wp94639 · Caroline Topping HMP Coldingley lacked systems for recording welfare information, collating prisoner details, checking mental health referrals, and providing out-of-hours clinical mental health support, …	South East Surrey	HMP Coldingley HMPPS Ministry of Justice NHS England	3/4
28 Oct 2024	Margaret Daly 2024-0701 · John Gittins A clinician prescribed a sedative without reviewing the patient's full medical records, leading to unawareness of her enhanced falls risk and demonstrating …	Wales North Wales (East and Central)	Betsi Cadwaladr University Health Board	1/1
20 Dec 2024	Antony Williamson 2024-0700 · Adrian Farrow A lack of formal communication frameworks between different NHS specialties and Trusts, especially in complex mental health and pain cases, resulted in …	North West Manchester South	Department of Health and Social …	1/1
20 Dec 2024	Oliver Winson 2024-0699 · Samantha Goward Patients with undiagnosed or untreated ADHD face excessively long waiting lists, leading to potential deterioration, harmful behaviors, and increased risk of death.	East of England Norfolk	NHS England	2/1
20 Dec 2024	David Haw 2024-0698 · Rachael Griffin The provided text is incomplete and does not contain discernible coroner's concerns regarding future deaths.	South West Dorset	Department for Transport Offshore Racing Council Royal Yachting Association	2/3
19 Dec 2024	Andrew Lewis 2024-0697 · Heidi Connor Systemic and prolonged ambulance service capacity issues, coupled with extensive hospital handover delays, led to extreme response times, with national concerns about …	South East Berkshire	Department of Health and Social … NHS England	2/2