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 7 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
19 Mar 2026	Paul Nash 2026-0161 · Emma Whitting A GP surgery failed to prioritise urgent seizure medication, and epilepsy patients nationally face difficulties obtaining sufficient quantities, leading to poor seizure …	East of England Bedfordshire and Luton	Department of Health and Social … Sundon Medical Centre	2/2
19 Mar 2026	Graham Oxley 2026-0160 · Carl Fitch Unreliable systems for immunotherapy toxicity mean urgent oncology advice is delayed by triage, and patient alert cards do not trigger a dedicated …	South Yorkshire	Sheffield Teaching Hospital NHS Foundation …	1/1
20 Mar 2026	Luke Ashcroft 2026-0159 · Paul Smith Corded telephones in CSU cells pose a clear self-harm risk when suspended, and unreliable provision of telephone access prevents prisoners in crisis …	East Midlands Lincolnshire	HMP Lincoln Ministry of Justice	2/2
19 Mar 2026	John Beagley 2026-0158 · Roland Wooderson A national shortage of maxillofacial surgeons, exacerbated by unfunded training elements, is impacting patient care and deterring prospective candidates.	South West Gloucestershire	Department of Health and Social …	1/1
20 Mar 2026	Lee Adams 2026-0157 · Julian Morris Doctors, particularly GPs, require greater awareness of propranolol's high toxicity at small doses and the lack of a specific antidote for overdose.	London Inner South London	Medicines and Healthcare products Regulatory …	1/1
20 Mar 2026	Lee Adams 2026-0156 · Julian Morris GPs need greater awareness of propranolol's high toxicity at small doses, its lack of antidote, and the need to proactively inquire about …	London Inner South London	Royal College of General Practitioners	1/1
23 Mar 2026	Richard Hopkins 2026-0155 · Linda Lee An unrecognised proximity risk exists from sudden, unexpected failure of pressurised air suspension systems during undisturbed visual inspections, unsupported by current guidance …	West Midlands Coventry and Warwickshire	Driver and Vehicle Standard Agency Health and Safety Executive Society of Motor Manufacturers and …	2/3
23 Mar 2026	Peter Coates 2026-0154 · Paul Appleton There is a critical gap in ambulance response categories, as some patients requiring an immediate response to prevent life-threatening deterioration do not …	North East Teesside and Hartlepool	NHS England	1/1
5 Mar 2026	Joanna Hillard 2026-0128 · Samantha Marsh The Mental Capacity Act 2005 and current understanding fail to adequately recognise how controlling and coercive behaviour can impair a person's decision-making …	South West Somerset	Department of Health and Social …	1/1
22 Dec 2025	Wendy Eyles 2026-0153 · Hassan Shah A lack of protocol for patients receiving both NHS and private psychiatric care leads to poor communication regarding medication changes, risking patient …	East Midlands Northamptonshire	Northamptonshire Healthcare NHS Foundation Trust Northamptonshire Integrated Care Board	1/2
10 Mar 2026	Darryl Johnson 2026-0152 · Emma Whitting Inaccurate and outdated address information in the ambulance service's mapping database, even for long-established properties, created delays in emergency response, risking patient …	East of England Bedfordshire and Luton	Ordnance Survey	1/1
16 Mar 2026	Darren Dickson 2026-0151 · Andrew Cousins Poor record-keeping meant that information and signposting provided to the patient were unclear, and inadequate communication between services led to conflicting advice …	North West Cumbria	Recovery Steps	1/1
16 Mar 2026	Darren Dickson 2026-0150 · Andrew Cousins Inadequate policies allowed supervision records to be overwritten and subsequently destroyed, preventing accurate ascertainment of information and raising concerns about proper record …	North West Cumbria	Cumbria, Northumberland, Tyne & Wear …	2/1
11 Mar 2026	Charlotte Jones 2026-0149 · Kirsty Gomersal Information sharing procedures between different health services are inadequate, failing to ensure the proper exchange of service user information regardless of treatment …	North West Cumbria	Cumbria, Northumberland, Tyne & Wear … Recovery Steps Cumbria	1/2
4 Mar 2026	Roman Barr 2026-0148 · Linda Lee Concerns include poor patient awareness and clinical follow-up for salbutamol overuse, prolonged ambulance handover delays impacting emergency availability, and unclear NHS Pathways …	West Midlands Coventry	Asthma & Lung Care Quality Commission Department of Health and Social … NHS England	4/6
10 Mar 2026	Sheila Creegan 2026-0147 · Graeme Irvine The Trust failed to conduct a proper patient safety investigation into the death despite clear errors, including an inaccurate initial cause of …	London East London	Barking, Havering and Redbridge University … Department of Health and Social …	2/2
12 Mar 2026	Paul Green 2026-0146 · Gareth Jones The current system allows inexperienced 17-year-old drivers to drive unsupervised with teenage passengers, which is a factor in collisions and increases the …	South East West Sussex, Brighton and Hove	Department for Transport	1/1
27 Feb 2026	David Fenn 2026-0145 · Lincoln Brookes Sepsis was not recognised or managed correctly, consultant review was delayed and hampered by poor communication, and junior staff felt unable to …	East of England Essex	Colchester General Hospital East Suffolk and North Essex …	1/2
11 Mar 2026	Malcolm Welch 2026-0144 · Mark Armitage Inconsistent provision of mobility aids during patient transfers between hospital wards, as walking frames do not automatically follow patients, posing a fall …	Yorkshire and the Humber North Yorkshire and York	York & Scarborough Teaching Hospitals …	1/1
12 Mar 2026	Tania Jarman 2026-0143 · Elizabeth Wheeler Persistent shortage of mental health beds risks lives, and clinicians may apply an artificially high threshold for admission due to system pressures.	North West Cheshire	Department of Health and Social …	1/1