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 8 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
10 Mar 2026	Jennine Romeo 2026-0142 · Alison Hewitt A critical echocardiogram result was not reviewed by a clinician for months, as no system ensured timely review when appointments were cancelled, …	London City of London	North Middlesex university Hospital Royal Free London NHS Foundation …	2/2
10 Mar 2026	Surendrakumar Patel 2026-0141 · James Puzey Healthcare staff lacked awareness of the food refusal policy and failed to conduct necessary mental capacity assessments for patients refusing food.	West Midlands Worcestershire	Government Legal Department Midlands Partnership NHS Foundation Trust Practice Plus Group	3/3
11 Mar 2026	Janette Palmer 2026-0140 · Nigel Parsley A housing association was unaware of the UK Power Networks Priority Services Register, risking vulnerable residents not receiving enhanced support during power …	East of England Suffolk	Department of Health and Social …	1/1
11 Mar 2026	Mark Simpson 2026-0139 · Alan Wilson NHS 111 reports to GP practices are not always reviewed by medically qualified staff, and critical information is often not added to …	North West Blackpool & Fylde	Department of Health and Social … Royal College of General Practitioners	2/2
10 Mar 2026	Ruairi Stewart 2026-0138 · Elizabeth Wheeler Failures include inadequate MDT input and inaccurate reports, lack of accountability for drug testing, poor documentation of leave decisions and substance misuse, …	North West Cheshire	Alternative Futures Group	1/1
10 Mar 2026	John Loannou 2026-0137 · Graeme Irvine Barts Health Trust failed to investigate a patient's death under the NHS Patient Safety Framework, missing crucial learning opportunities regarding infection causes …	London East London	Barts Health NHS Trust Department of Health and Social …	0/2
9 Mar 2026	Taylor Maddox 2026-0136 · Stephen Covell Psychiatric patients discharged from hospital face inadequate housing support due to poor communication with housing services and assessment processes that do not …	South West Devon, Plymouth and Torbay	North Devon Council	1/1
9 Mar 2026	Terrence Frost 2026-0135 · Nigel Parsley GPs and internal hospital staff experienced significant difficulties contacting the Medical Assessment Unit and A&E to pre-alert them about seriously unwell patients, …	East of England Suffolk	East Suffolk & North Essex …	1/1
16 Dec 2025	Walter Pollyn 2026-0134 · Ian Potter Nursing staff repeatedly failed to adhere to 'nil by mouth' instructions despite clear documentation and visual cues, indicating potential underlying attitudinal issues …	South East Kent and Medway	Medway NHS Foundation Trust	1/1
6 Mar 2026	Asher Blackman 2026-0133 · Andrew Walker District Nurses failed to record next of kin details and the 'no access' policy was inadequate, lacking provision for police involvement when …	London North London	Central London Community Healthcare NHS …	1/1
6 Mar 2026	Kay Wilson 2026-0132 · Jeremy Chipperfield An unguarded breach in a stone wall provides unrestricted public access to a dangerous 9-meter vertical drop onto rocks and the river …	North East County Durham and Darlington	Durham County Council	1/1
6 Mar 2026	Alan Tomlinson 2026-0131 · Martin Lanchester A pacemaker clinic failed to refer a visibly unwell patient with high thresholds to cardiology, contributed to a delayed diagnosis. Concerns include …	Wales Gwent	Cardiff and Vale University Health …	1/1
27 Feb 2026	Louis Saunders 2026-0130 · Laura Bradford Poor communication and coordination between private ADHD clinics and NHS GPs led to duplicate prescriptions for different medications, risking patient confusion and …	South East East Sussex	NHS England	1/1
5 Mar 2026	Caroline Adeyelu 2026-0129 · Nadia Persaud Mental health services demonstrated a poor appreciation of risks from an adult child's mental illness to a parent, due to insufficient safeguarding …	London East London	East London Foundation Trust Metroplolis North East London Foundation Trust	3/3
19 Nov 2025	Anna Burns 2026-0127 · Grant Davies The methadone prescribing agency was unaware of the patient's prior opioid overdose and hospital admission because discharge summaries were not shared with …	South West Wiltshire and Swindon	Great Western Hospital	0/1
27 Feb 2026	Brema Virgo 2026-0126 · Frazer Stuart Flawed methods for assessing pavement defect heights result in relevant hazards not being identified and remedial action not being taken, creating a …	Wales Gwent	Newport City Council – Highways	1/1
3 Mar 2026	Mujahid Adam 2026-0125 · Edwin Buckett Inaccurate, non-contemporaneous recording of prisoner observations and an unclear definition of what constitutes an "observation" were identified. A disrepaired special cell, used …	London Inner North London	HMP Pentonville HMPPS Ministry for Justice	1/3
4 Mar 2026	Oriel Vasey 2026-0124 · Abigial Combes An unchanged ICB form, intended for financial decisions, incorrectly includes an allergy section. This led to inaccurate clinical records and suboptimal patient …	North East Sunderland	NHS North East and North …	1/1
4 Mar 2026	Mark Hughes 2026-0123 · Benjamin Myers Systemic delays in urgent mental health referrals to Home Based Treatment Teams, combined with the inability of general practice professionals to make …	North West Manchester South	Greater Manchester Mental Health NHS …	1/1
4 Mar 2026	Viviana-Ray Butnaru 2026-0122 · Jyoti Gill A lack of national guidelines exists for assessing paediatric heart conditions like myocarditis, coupled with insufficient awareness of Parvovirus. Locally, critical radiology …	East of England Essex	Basildon Hospital (Mid & South … Royal College of Paediatrics and …	2/2