Prevention of Future Deaths Reports
JudiciaryBrowse 6,327 coroners' Regulation 28 reports by year, region, organisation, category, or keyword.
Data sourced from judiciary.uk under the Open Government Licence.
6,327 reports
· Page 1 of 317
Showing 20 at a time
| Date | Report | Region / area | Addressee(s) | Status | Responses |
|---|---|---|---|---|---|
| Unknown |
Thomas Mayhew
2026-0225
· Laura Bradford
|
South East
East Sussex
|
Department for Science, Innovation and … National Police Chiefs’ Council | Response Pending | 0/2 |
| Unknown |
Kay Wilson
2026-0132-wp123915
· Jeremy Chipperfield
A breach in a stone wall near County Bridge, Barnard Castle, allows unrestricted access to a 9-meter drop onto rocks and the …
|
North East
County Durham and Darlington
|
Durham County Council | All Responded | 1/1 |
| Unknown |
David Roomes
2026-0222
· Ian Potter
The report identifies a significant delay in triaging referrals, compounded by a poorly executed initial triage, potentially reflecting a wider training issue …
|
South East
Kent and Medway
|
Kent & Medway NHS Mental … | Response Pending | 0/1 |
| Unknown |
Ellie Herron
2026-0226
· Paul Marks
The park is frequented by individuals who sell and abuse drugs, drink alcohol, and sleep rough; this puts vulnerable individuals at high …
|
Hull and East Riding
|
Chief Constable of Humberside Police | Response Pending | 0/1 |
| Unknown |
Lisa Taylor-Penny
2026-0220
· Elizabeth Wheeler
The rigid implementation of "Right care right person" (RCRP) may limit call handlers' ability to escalate calls to senior staff, even when …
|
North West
Cheshire
|
Cheshire Police | Response Pending | 0/1 |
| Unknown |
Paul Hutchinson
2026-0223
· Richard Furniss
Fire safety regulations may not specifically address individual flats within Extra Care Supported Accommodation (ECSA), potentially leaving vulnerable residents at risk due …
|
London
West London
|
Care Quality Commission Local Government Association Minister for Housing Communities and … National Fire Chiefs Council | Response Pending | 0/4 |
| Unknown |
James Stewart
2026-0221
· Robert Cohen
Flow Coordinators arranging patient discharges may lack information about patient vulnerabilities, potentially leading to unsuitable arrangements being made.
|
North West
Cumbria
|
North Cumbria Integrated Care NHS … | Response Pending | 0/1 |
| Unknown |
Albert Bellingham
2026-0176
· Andrew Walker
There is a need for guidance and training to support doctors working in care homes in an interventional, supervisory role when dealing …
|
London
North London
|
Department of Health and Social … | Response Pending | 0/1 |
| 14 Apr 2026 |
Susan Toft
2026-0214
· Andrew Bridgman
The detachment of a wheelchair seat cushion after only 9 months raised concerns about the robustness of the attachment method, and a …
|
North West
Manchester South
|
British Health Trades Association Wheelchair Alliance Wheelchair Accessible Vehicle Converters Association | Response Pending | 0/3 |
| 14 Apr 2026 |
Catherine Oliver
2026-0215
· Nicholas Graham
Prolonged storage of household items in the main living area created a hazard for an elderly tenant, and there were no clear …
|
South East
Oxfordshire
|
Sanctuary Housing Association | Response Pending | 0/1 |
| 14 Apr 2026 |
Kiefer Fraser-Phillips
2026-0216
· Louise Hunt
Therapeutic observations were not accurately recorded due to Wi-Fi signal issues, and there was no care plan in place to address the …
|
West Midlands
Birmingham and Solihull
|
Birmingham and Solihull Mental Health … | Response Pending | 0/1 |
| 10 Apr 2026 |
Garry Mills
2026-0212
· Darren Stewart
The coroner raises concerns that the £250 per week allowance for reasonable living expenses under Proceeds of Crime Act Restraint Orders, which …
|
South East
Surrey
|
Attorney General of England and … Public Prosecutions | Response Pending | 0/2 |
| 10 Apr 2026 |
Wayne Austin
2026-0213
· Heath Westerman
Difficulties locating the appropriate cardiac arrest guidance on the JRCALC app, the inability of paramedics to comply with respiratory arrest guidelines, and …
|
West Midlands
Shropshire, Telford and Wrekin
|
Joint Royal Colleges Ambulance Liaison … West Midlands Amublance Service | Response Pending | 0/2 |
| Unknown |
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 | Response Pending | 0/2 |
| 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 … | Response Pending | 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 | Response Pending | 0/5 |
| 8 Apr 2026 |
Gary Starbuck
2026-0204
· Darren Stewart
The coroner expressed concern that patients receiving private care for skin cancers may receive inferior care compared to NHS patients, due to …
|
South East
Surrey
|
Care Quality Commission Royal College of Surgeons | Response Pending | 0/2 |
| Unknown |
Coroner name:
2026-018
· Coroner Area:
The police search for a missing person was hampered by inaccurate recording of location and search outcomes, and a failure to act …
|
Category:This report is being sent to:
|
Cleveland Police REGULATION 28 REPORT TO PREVENT … | Response Pending | 1/2 |
| 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 … | Response Pending | 0/1 |
| 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 … | Response Pending | 0/2 |
Thomas Mayhew
Response Pending
Department for Science, Innovation …
National Police Chiefs’ Council
Kay Wilson
All Responded
A breach in a stone wall near County Bridge, Barnard Castle, allows unrestricted access to a 9-meter drop onto rocks and the River Tees.
Durham County Council
David Roomes
Response Pending
The report identifies a significant delay in triaging referrals, compounded by a poorly executed initial triage, potentially reflecting a wider training issue within the …
Kent & Medway NHS …
Ellie Herron
Response Pending
The park is frequented by individuals who sell and abuse drugs, drink alcohol, and sleep rough; this puts vulnerable individuals at high risk due …
Chief Constable of Humberside …
Lisa Taylor-Penny
Response Pending
The rigid implementation of "Right care right person" (RCRP) may limit call handlers' ability to escalate calls to senior staff, even when other professionals …
Cheshire Police
Paul Hutchinson
Response Pending
Fire safety regulations may not specifically address individual flats within Extra Care Supported Accommodation (ECSA), potentially leaving vulnerable residents at risk due to a …
Care Quality Commission
Local Government Association
Minister for Housing Communities …
James Stewart
Response Pending
Flow Coordinators arranging patient discharges may lack information about patient vulnerabilities, potentially leading to unsuitable arrangements being made.
North Cumbria Integrated Care …
Albert Bellingham
Response Pending
There is a need for guidance and training to support doctors working in care homes in an interventional, supervisory role when dealing with pressure …
Department of Health and …
Susan Toft
Response Pending
The detachment of a wheelchair seat cushion after only 9 months raised concerns about the robustness of the attachment method, and a lack of …
British Health Trades Association
Wheelchair Alliance
Wheelchair Accessible Vehicle Converters …
Catherine Oliver
Response Pending
Prolonged storage of household items in the main living area created a hazard for an elderly tenant, and there were no clear policies or …
Sanctuary Housing Association
Kiefer Fraser-Phillips
Response Pending
Therapeutic observations were not accurately recorded due to Wi-Fi signal issues, and there was no care plan in place to address the physical health …
Birmingham and Solihull Mental …
Garry Mills
Response Pending
The coroner raises concerns that the £250 per week allowance for reasonable living expenses under Proceeds of Crime Act Restraint Orders, which has not …
Attorney General of England …
Public Prosecutions
Wayne Austin
Response Pending
Difficulties locating the appropriate cardiac arrest guidance on the JRCALC app, the inability of paramedics to comply with respiratory arrest guidelines, and insufficient Naloxone …
Joint Royal Colleges Ambulance …
West Midlands Amublance Service
Rickie Poon
Response Pending
Failures in the ACCT process at HMP Pentonville, including poor management and implementation, insufficient accountability, and gaps in training, contributed to the death. Additionally, …
HM Prison Pentonville
Practice Plus Group
Richard Whelan
Response Pending
The coroner noted that non-urgent referrals to the Single Point of Access (SPA) for mental health support may take up to 14 days to …
South West Yorkshire Partnership …
Jonathan Thornton
Response Pending
Information sharing barriers between the Community Forensic Team and prison healthcare, as well as between prison healthcare and operational prison staff, were identified as …
HMP Nottingham
Ministry of Justice
Northampton Healthcare NHS Foundation …
Gary Starbuck
Response Pending
The coroner expressed concern that patients receiving private care for skin cancers may receive inferior care compared to NHS patients, due to a lack …
Care Quality Commission
Royal College of Surgeons
Coroner name:
Response Pending
The police search for a missing person was hampered by inaccurate recording of location and search outcomes, and a failure to act on heat …
Cleveland Police
REGULATION 28 REPORT TO …
Joshua Perry
Response Pending
A conflict exists between Building Regulations and BSI Standards regarding the measurement of barrier heights when a wall or parapet is used as guarding, …
Secretary of State for …
Mark Smith
Response Pending
The report identifies concerns about the potential for incorrect medication dosages to be prescribed or administered, the risk of patients being discharged back to …
1. Chief Executive Officer, …
Chief Executive Officer, Practice …
2. Chief Executive Lewisham …