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 5 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
2 Feb 2026	Janet Daniels 2026-0202 · Sean Horstead There was a failure to communicate effectively with the patient and her family regarding critical clinical decision-making and the basis for such …	East of England Essex	East Suffolk and North Essex …	1/1
31 Mar 2026	John Hay 2026-0189 · Hassan Shah Risk assessments in the care plan were not completed or reviewed with nursing or medical input, and the escalation process for medical …	East Midlands Northamptonshire	CQC QCC Care Bureau West Northamptonshire Council	3/4
30 Mar 2026	John Tarrant 2026-0199 · Robert Simpson Falls risk assessments were carried out based on incorrect data, and the Trust lacked a way of auditing their accuracy; a doctor …	South East Berkshire	Frimley Health NHS Foundation Trust	0/1
8 Apr 2026	Jonathan Thornton 2026-0200 · Alexandra Pountney Information sharing barriers between the Community Forensic Team and prison healthcare, as well as between prison healthcare and operational prison staff, were …	East Midlands Nottingham and Nottinghamshire	HMP Nottingham Ministry of Justice Northampton Healthcare NHS Foundation Trust Nottingham Healthcare NHS Foundation Trust	0/5
7 Apr 2026	Joshua Perry 2026-0206 · Helen Rimmer A conflict exists between Building Regulations and BSI Standards regarding the measurement of barrier heights when a wall or parapet is used …	North West Liverpool & Wirral	Secretary of State for building … Secretary of State for building …	1/2
1 Apr 2026	Lucy Phelan 2026-0209 · David Reid The use of the "latching" facility on patient monitoring equipment may contribute to alarm fatigue, making it difficult for staff to respond …	West Midlands Worcestershire	NHS Wales NHS England Worcestershire Acute Hospital NHS Trust	1/3
8 Feb 2026	Luke Abrahams 2026-0201 · Sophie Lomas There are difficulties in diagnosing necrotising fasciitis, and the NHS website does not make it clear that the condition can present as …	East Midlands Northamptonshire	NHS England	1/1
7 Apr 2026	Mark Smith 2026-0205 · Jenny Goldring The report identifies concerns about the potential for incorrect medication dosages to be prescribed or administered, the risk of patients being discharged …	London Inner South London	1. Chief Executive Officer, Practice … Chief Executive Officer, Practice Plus … 2. Chief Executive Lewisham and … 3. The Director at HMP …	0/6
7 Apr 2026	Matilda Davis 2026-0198 · Deborah Sewell Suicide prevention training is not mandatory for frontline practitioners within Warwickshire Children’s Services, potentially leading to variability in practice when responding to …	West Midlands Warwickshire	Warwickshire County Council – Children … Warwickshire County Council – Children …	1/2
2 Apr 2026	Peter Pettit 2026-0196 · Darren Stewart Inadequate record keeping, poor medication management support, and deficient catheter management were identified in community care services. There were also concerns that …	East of England Suffolk	Multi-Care Community Services Suffolk	1/1
9 Apr 2026	Richard Whelan 2026-0208 · Peter Merchant The coroner noted that non-urgent referrals to the Single Point of Access (SPA) for mental health support may take up to 14 …	Yorkshire and the Humber West Yorkshire Western	South West Yorkshire Partnership NHS …	1/1
3 Apr 2026	Roman Barr 2026-0197 · Linda Lee The report identifies limited awareness of salbutamol overuse, inconsistent identification and follow-up of reliever overuse, ambulance handover delays affecting emergency availability, risks …	West Midlands Coventry	Asthma & Lung (for information) Care Quality Commission NHS England NHS Pathways/NHS Digital (NHS England …	0/6
4 Jan 2026	Rickie Poon 2026-0194 · Mary Hassell Failures in the ACCT process at HMP Pentonville, including poor management and implementation, insufficient accountability, and gaps in training, contributed to the …	London Inner North London	HM Prison Pentonville Practice Plus Group	2/2
31 Mar 2026	Jack Saunders 2026-0187 · James Newman Borrowed equipment lacked instructions, and while national carbon monoxide poisoning risk training existed, it had not reached trainers within individual troops; the …	North West Lancashire with Blackburn and Darwen	Scouting Association	1/1
30 Mar 2026	Grant Lowry 2026-0186 · Clare Bailey The police search for a missing person was hampered by inaccurate recording of location and search outcomes, and a failure to act …	North East Teesside & Hartlepool	Cleveland Police REGULATION 28 REPORT TO PREVENT …	2/2
26 Mar 2026	Melanie Pinnell 2026-0185 · Daniel Sharpstone No follow-up was offered to the deceased by the GP practice after she described suicidal ideation and suicidal thoughts; a Consultant Psychiatrist's …	East of England Suffolk	Unity Healthcare	1/1
27 Mar 2026	Edith Millington 2026-0183 · Andrew Bridgman The structure/design of the store's access ramp is unsafe, because it is not fixed to the ground, the rubber mat is not …	North West Manchester South	Sai SKN Ltd	1/1
31 Mar 2026	Raisa Iordan 2026-0190 · Charlotte Keighley A junior doctor's concerns were ignored by a senior doctor, whose assessment was limited; out-of-hours radiology interpretation was provided by an agency …	Yorkshire and the Humber West Yorkshire Western	Mid Yorkshire Teaching Hospital NHS … Telemedicine Clinic Limited	2/2
30 Mar 2026	Oliver Roberts 2026-0184 · Rachael Griffins There is a lack of practical guidance for police officers on applying their powers to obtain communications data under the Investigatory Powers …	South West Dorset	National Police Chiefs' Council College of Policing Devon and Cornwall Police Dorset Healthcare NHS Trust	2/5
1 Apr 2026	Susan Whittles 2026-0191 · Lorraine Harris Nationals of non-designated countries who fail a GB driving test can continue to drive in the UK for up to 12 months …	Yorkshire and the Humber East Riding and Hull	Department for Transport Driver and Vehicle Standards Agency	1/2