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 6 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
26 Mar 2026	Elizabeth Lang and Katie Lang 2026-0182 · Andrew Hetherington Surface friction was low at the collision site, and while the council had undertaken roadworks, there was no advance warning signage alerting …	North East Northumberland	Northumberland County Council	1/1
18 Mar 2026	Clare Dupree 2026-0181 · M Vision In-cell automatic fire detection is still to be fully implemented at Eastwood Park prison and across a number of prisons in the …	South West Avon	Director General Operations Ministry of Justice	1/2
26 Mar 2026	Madison Smith 2026-0179 · Alison Mutch There is no statutory regulation of agencies or individuals offering sleep routine services for young children, and anyone can attach the term …	North West Manchester South	Department of Health and Social …	1/1
10 Nov 2025	Costas Chrysostomou 2026-0177 · Ian Potter There is potential for confusion due to differing interpretations of the term 'urgent' in cardiology pathways, and a lack of clarity among …	London Inner North London	NHS North Central London Integrated …	1/1
15 Mar 2026	Ruslans Burkevics 2026-0175 · Michael Pemberton Front line police officers receive regular refresher training on first aid, but no similar provision is in place for mental health first …	North West Manchester West	Greater Manchester Police	1/1
1 Apr 2026	Benjamin Rowley 2026-0192 · Paul Smith Two incidents at a dialysis centre involved the detachment of a port from a Covidien Palindrome Chronic Dual Lumen Catheter, leading to …	East Midlands Greater Lincolnshire	Medicines and Healthcare Products Regulatory … Medtronic Limited University Hospitals of Leicester NHS …	3/3
26 Mar 2026	Alex Ganski 2026-0180 · Joseph Turner There was no designated lead with oversight and authority over the deceased's care, and a 'care gap' resulted in fragmented information sharing …	South East West Sussex, Brighton and Hove	Department of Health and Social …	1/1
16 Mar 2026	Jardine Williams 2026-0174 · Andrew Cousins Communication between NWAS and CHOC was unclear, resulting in limited information transfer and significant delays in CHOC returning calls to NWAS after …	North West Cumbria	Northwest Ambulance Service	1/1
16 Mar 2026	Jardine Williams 2026-0173 · Andrew Cousins The 999 call pathway for mental health crises lacks a specific question to assess the immediacy of a stated suicide plan, potentially …	North West Cumbria	NHS England	2/1
24 Mar 2026	Thomas Ruggiero 2026-0172 · Ian Potter Key issues include a vulnerable cell bell system that can be silenced externally, staff failing to complete critical ACCT documentation, and confusion …	Ian Potter	HMP Swaleside	1/1
24 Mar 2026	Thomas Ruggiero 2026-0171 · Ian Potter Healthcare team, particularly mental health staff, inconsistently attended ACCT reviews, leaving vulnerable prisoners without adequate safety netting and protective measures.	Ian Potter	Oxlease NHS Foundation Trust	1/1
24 Mar 2026	Thomas Ruggiero 2026-0170 · Ian Potter Widespread reliance on inexperienced, probationary prison officers across the prison estate leads to poor communication, lack of control, and increased risk of …	Ian Potter	Department for Prison, Probation and …	0/1
24 Mar 2026	Robert Day 2026-0169 · Ian Potter Frontline emergency services lack national guidance for managing complex, time-critical mental health crises where existing legal powers may be insufficient or unclear, …	South East Kent and Medway	Department for Women’s Health and … Department of Health and Social … Home Office	3/3
24 Mar 2026	Ronald Meikle 2026-0168 · Sean Cummings Key concerns include widespread availability of illicit drugs, inconsistent response to intoxication, fragmented information sharing, blocked observation panels, and inadequate support for …	South East Milton Keynes	Central & North West London … Chief Inspector of Prisons HMPPS HMP Woodhill	2/6
19 Mar 2026	James Coates 2026-0167 · Robert Cohen The current system relies inadequately on drivers self-reporting medical conditions to the DVLA, as doctors are not required to report, risking unreviewed …	North West Cumbria	Department for Transport	1/1
19 Mar 2026	John Fisher 2026-0166 · Karen Taylor Poor information transfer between healthcare teams, inaccurate medication records, and inadequate handovers between care providers risk patients receiving incorrect or missed essential …	South East West Sussex, Brighton and Hove	Coastal Homecare Sussex Community NHS Foundation Trust	2/2
17 Mar 2026	Delwyn Preece 2026-0165 · Louise Slater Ward leave was granted without mental state exams or risk assessments, and medical records suffered from poor detail and unacknowledged retrospective entries, …	Yorkshire and the Humber South Yorkshire East	Rotherham Doncaster South Humber NHS …	1/1
18 Mar 2026	Julie Pytches 2026-0164 · Sonia Hayes Issues included unshared anaesthetist limitations, staff confusion over emergency protocols and local variations, and unclear procedures for ambulance calls to private hospitals.	East of England Essex	Nuffield Health	1/1
18 Mar 2026	Edna Wiggett 2026-0163 · Robin Weyell Ambulance dispatch was delayed due to a failure to re-triage and re-classify a patient's case after receiving updated information about increased pain.	East of England Norfolk	East of England Ambulance NHS …	1/1
17 Mar 2026	Natalie Ainsworth 2026-0162 · Janine Richards Critical information about a vulnerable missing person's suicide threat was not passed to officers, resulting in an inaccurate police risk assessment and …	North East County Durham and Darlington	Durham Police	1/1