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.
Reports
| Date | Report | Responses identified |
|---|---|---|
| 3 Mar 2026 |
Wendy Boddington
2026-0121 · Peter Nieto
A significant number of patients on long-term, high-dose opiate/opioid prescriptions lack support to reduce or stop medication. There is an absence of …
|
1/1 |
| 2 Mar 2026 |
Susan Samson
2026-0120 · Rebecca Sutton
Excessive delays by the council in fitting a requested second banister rail in a tenant's home exposed the individual to a prolonged, …
|
0/1 |
| 27 Feb 2026 |
Maisie Almond
2026-0119 · Adrian Farrow
A national shortage of donor livers, particularly for "super urgent" children, is exacerbated by clinical guidance. This has led to extended waiting …
|
2/2 |
| 27 Feb 2026 |
Summer Mant
2026-0118 · Rachel Knight
A delay in obtaining adrenaline during resuscitation occurred due to non-standardised paediatric crash trolleys across hospitals, hindering junior doctors in a time-critical …
|
3/10 |
| 26 Feb 2026 |
William Webb
2026-0117 · Victoria Davies
A canal near student accommodation lacks safety equipment and warning signage, making it difficult for inebriated individuals to exit the water if …
|
0/1 |
| 25 Feb 2026 |
Urmila Patel
2026-0116 · Graeme Irvine
Nursing failures included inadequate falls risk assessment, poor care-planning, and insufficient monitoring. Doctors also failed to decisively assess for intracranial bleeding or …
|
2/2 |
| 25 Feb 2026 |
Emma Turner
2026-0115 · Sabyta Kaushal
Poor information sharing and lack of system connectivity between agencies hindered care for a vulnerable adult. The GP safeguarding referral form was …
|
1/2 |
| 24 Feb 2026 |
Patrick Griffin
2026-0114 · Chris Morris
A patient with advanced dementia became dehydrated and severely constipated at a care facility, despite recognized needs for dietary, fluid, and personal …
|
1/1 |
| 26 Feb 2026 |
Yunus Hoque
2026-0113 · Benjamin Myers
NWAS failed to communicate significant ambulance delays to callers, even when a patient's condition deteriorated from Category 2 to 1. This lack …
|
1/1 |
| 23 Feb 2026 |
Susan Samson
2026-0112 · Rebecca Sutton
A patient was discharged home without consistently demonstrating safe stair use, and the current policy would allow this to recur, posing a …
|
2/1 |
| 16 Sep 2025 |
Hilary Chapman
2026-0111 · Simon Connolly
The updated section 17 leave policy does not reflect the new processes for discussing and prescribing leave, creating a gap between practice …
|
1/1 |
| 8 Feb 2026 |
John Franklin
2026-0110 · Sarah Murphy
A high-risk falls patient was discharged home before a careline/lifeline pendant was provided, delaying assistance when the patient subsequently fell.
|
1/1 |
| 25 Feb 2026 |
Lesley Krommendijk
2026-0109 · Jyoti Gill
Discharge assessment processes led to an unrealistic impression of the patient's mobility, potentially compromising patient safety.
|
2/1 |
| 25 Feb 2026 |
Raymond Moran
2026-0108 · Paul Marks
The falls risk assessment was inaccurate, not updated, and documentation was incomplete.
|
1/1 |
| 5 Feb 2026 |
Angela Darlow
2026-0107 · Kate Robertson
Critically long ambulance delays, exacerbated by hospital handover issues, led to patients missing crucial time-sensitive treatments like thrombectomy for stroke.
|
1/2 |
| 22 Dec 2025 |
Elaine Griffiths
2026-0106 · Hassan Shah
Inconsistent and partially completed fluid/diet charts, confusion regarding dietary intolerances, limited suitable food options, and unrecorded external food intake hindered accurate nutritional …
|
1/1 |
| 20 Feb 2026 |
Sean Williams
2026-0105 · Ian Potter
A custody nurse failed to take vital signs before prescribing medication. Serco staff critically delayed first aid, didn't use emergency alerts, and …
|
2/2 |
| 19 Feb 2026 |
Jane Fenwick
2026-0104 · Hassan Shah
A patient with multiple choking risk factors was not referred for Speech and Language Therapy due to high intervention thresholds and long …
|
2/2 |
| 20 Feb 2026 |
Alan Crabtree
2026-0103 · Elizabeth Wheeler
Outdated methotrexate guidelines recommend a sub-therapeutic dose and create ambiguity in responsibilities between healthcare providers, risking fatal delays in toxicity management.
|
2/1 |
| 19 Feb 2026 |
Jacqueline Joseph
2026-0102 · Bina Patel
The housing association property had two incorrectly installed battery-operated smoke alarms, posing a fire safety risk.
|
1/1 |