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 10 of 317
Showing 20 at a time
| Date | Report | Region / area | Addressee(s) | Status | Responses |
|---|---|---|---|---|---|
| 19 Jan 2026 |
Martin Bryant
2026-0030
· Rebecca Mundy
Mental health crisis patients face dangerously long waits in open reception areas due to a severe lack of local and national mental …
|
East of England
Essex
|
Essex University Partnership Trust NHS England | All Responded | 2/2 |
| 16 Jan 2026 |
Wayne Walton
2026-0028
· Deborah Lakin
Inpatient staff lacked awareness of Home Treatment Team policies, leading to inadequate risk assessments and safety plans. There is also no guidance …
|
West Midlands
Coventry
|
Mental Health Directorate | All Responded | 1/1 |
| 15 Jan 2026 |
Ronald Nelson
2026-0024
· Sarah Wood
Concerns remain regarding poor record keeping and inadequate compliance with care plans, which pose a risk to future patient safety.
|
East Midlands
Nottingham City and Nottinghamshire
|
Care Quality Commission Mulberry Court Care Home | All Responded | 2/2 |
| 15 Jan 2026 |
Margaret Grimsley
2026-0022
· John Ellery
The apparent absence or non-use of an upper alarm setting on bedside oxygen meters risks over-oxygenation, with unclear policies on its implementation …
|
West Midlands
Shropshire, Telford and Wrekin
|
Shewsbury and Telford Hospital Trust | All Responded | 1/1 |
| 15 Jan 2026 |
Matilda Pomfret-Thomas
2026-0025
· Henry Charles
A lack of regulation, registration, and clear guidance for doulas creates confusion about their role, risks them working outside clinical boundaries, and …
|
South East
Hampshire, Portsmouth Southampton
|
Department of Health and Social … NICE Nursing and Midwifery Council | All Responded | 4/3 |
| 14 Jan 2026 |
Dorothy Hoyberg
2026-0019
· Melanie Lee
Extreme pressure on ambulance services, operating at REAP Level 4, resulted in severe delays, unmet targets, and inability to make welfare calls, …
|
London
Inner North London
|
Department of Health and Social … | All Responded | 1/1 |
| 14 Jan 2026 |
Mark Turner
2026-0065
· Emma Serrano
There is a critical absence of local or national guidance for managing the steps to be taken when a high serum level …
|
West Midlands
Staffordshire
|
Midlands Partnership Foundation Trust NHS England | All Responded | 2/2 |
| 14 Jan 2026 |
Oliver Long
2026-0021
· Laura Bradford
The self-exclusion scheme (GamStop) fails to protect individuals from unlicenced overseas gambling sites, which target vulnerable users. There is a critical lack …
|
South East
East Sussex
|
Department for Digital Culture, Media … Department for Education Department of Health and Social … Gambling Commission | All Responded | 4/4 |
| 14 Jan 2026 |
Stephen Taylor
2026-0020
· Sarah Clarke
Multiple services failed to coordinate risk escalation for escalating mental distress, relying on patient denial despite high-risk indicators. Urgent mental health referrals …
|
South East
Kent and Medway
|
Kent and Medway Mental Health … Vita health Group : Kent … | All Responded | 2/2 |
| 13 Jan 2026 |
Rory Williams
2026-0016
· Kate Robertson
The gastroenterology/endoscopy service suffers from critical staffing shortages, inadequate infrastructure, and excessively long waiting times. These systemic failures are not adequately reflected …
|
Wales
North Wales (East and Central)
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 13 Jan 2026 |
Heidi Williams
2026-0017
· Anne Pember
Evidence showed the deceased ordered numerous tablets from an individual linked to known addresses, but Essex Police have refused Northamptonshire Police's request …
|
East Midlands
Northamptonshire
|
Essex Police | All Responded | 1/1 |
| 13 Jan 2026 |
Peter Thompson
2026-0018
· Sarah Huntbach
Care home staff failed to perform routine blood sugar tests on a diabetic resident, delaying critical diagnosis. A lack of formal shift …
|
East Midlands
Derby and Derbyshire
|
Bank Close House Residential Care … | All Responded | 1/1 |
| 8 Jan 2026 |
David Dugdale
2026-0007
· Rachel Redman
Inadequate pain management, lack of nutritional support, and severe neglect of a pressure sore, exacerbated by nursing staff ignoring carers' concerns, led …
|
South East
East Sussex
|
East Sussex Healthcare NHS Trust | All Responded | 1/1 |
| 8 Jan 2026 |
Jean Waldron
2026-0009
· David Reid
An agency team leader disregarded clear instructions by providing inappropriate wound care, suggesting inadequate training on care limits and adherence to specialist …
|
West Midlands
Worcestershire
|
Ignite Health and Homecare Services | All Responded | 1/1 |
| 8 Jan 2026 |
Drew Greaves-Pimblett
2026-0008
· Anita Bhardwaj
National telephone triage pathways lack adequate guidance for call handlers on probing questions for critical symptoms like breathing and body temperature, hindering …
|
North West
Sefton, St Helens and Knowsley
|
NHS England | All Responded | 1/1 |
| 6 Jan 2026 |
Mohammed Choudhury
2026-0005
· Emma Whitting
Inadequate management of a patient's paranoid schizophrenia included failure to address non-concordance with anti-psychotic medication and withdrawal of medication support without GP …
|
East of England
Bedfordshire and Luton
|
East London NHS Foundation Trust | All Responded | 1/1 |
| 6 Jan 2026 |
Theo Tuikubulau
2026-0006
· Louise Wiltshire
Two distinct triage systems for 999 and 111 calls create a two-tiered ambulance categorisation for similar urgent breathing complications, potentially delaying critical …
|
South West
Devon, Plymouth and Torbay
|
NHS England | No Identified Response | 0/1 |
| 6 Jan 2026 |
Robert Gracey
2026-0004
· Paul Smith
Despite national recommendations, Lincolnshire lacks an established protocol to treat suspected Acute Behavioural Disturbance (ABD) as a medical emergency. The NHS Pathways …
|
East Midlands
Greater Lincolnshire
|
East Midlands Ambulance Service NHS … Lincolnshire Police NHS England | Partially Responded | 2/3 |
| 5 Jan 2026 |
Suzanne Pemberton
2026-0003
· Sean Horstead
The hospital lacks any specialist dietetic service outside weekday working hours, risking delays in crucial nutritional interventions like naso-gastric feeding and potential …
|
East of England
Essex
|
East Suffolk and North Essex … | All Responded | 1/1 |
| 5 Jan 2026 |
Adam Hussain
2026-0002
· Elizabeth Didcock
The urgent care pathway poorly serves serious systemic illnesses like sepsis, with critical patient information not reliably used by ambulance staff, leading …
|
East Midlands
Nottinghamshire
|
East Midlands Ambulance Service NHS … NHS England Nottingham and Nottinghamshire Integrated Care … Nottingham Emergency Medical Service | All Responded | 4/4 |
Martin Bryant
All Responded
Mental health crisis patients face dangerously long waits in open reception areas due to a severe lack of local and national mental health beds, …
Essex University Partnership Trust
NHS England
Wayne Walton
All Responded
Inpatient staff lacked awareness of Home Treatment Team policies, leading to inadequate risk assessments and safety plans. There is also no guidance for managing …
Mental Health Directorate
Ronald Nelson
All Responded
Concerns remain regarding poor record keeping and inadequate compliance with care plans, which pose a risk to future patient safety.
Care Quality Commission
Mulberry Court Care Home
Margaret Grimsley
All Responded
The apparent absence or non-use of an upper alarm setting on bedside oxygen meters risks over-oxygenation, with unclear policies on its implementation or whether …
Shewsbury and Telford Hospital …
Matilda Pomfret-Thomas
All Responded
A lack of regulation, registration, and clear guidance for doulas creates confusion about their role, risks them working outside clinical boundaries, and poses challenges …
Department of Health and …
NICE
Nursing and Midwifery Council
Dorothy Hoyberg
All Responded
Extreme pressure on ambulance services, operating at REAP Level 4, resulted in severe delays, unmet targets, and inability to make welfare calls, demonstrating that …
Department of Health and …
Mark Turner
All Responded
There is a critical absence of local or national guidance for managing the steps to be taken when a high serum level is returned …
Midlands Partnership Foundation Trust
NHS England
Oliver Long
All Responded
The self-exclusion scheme (GamStop) fails to protect individuals from unlicenced overseas gambling sites, which target vulnerable users. There is a critical lack of public …
Department for Digital Culture, …
Department for Education
Department of Health and …
Stephen Taylor
All Responded
Multiple services failed to coordinate risk escalation for escalating mental distress, relying on patient denial despite high-risk indicators. Urgent mental health referrals and family …
Kent and Medway Mental …
Vita health Group : …
Rory Williams
All Responded
The gastroenterology/endoscopy service suffers from critical staffing shortages, inadequate infrastructure, and excessively long waiting times. These systemic failures are not adequately reflected on the …
Betsi Cadwaladr University Health …
Heidi Williams
All Responded
Evidence showed the deceased ordered numerous tablets from an individual linked to known addresses, but Essex Police have refused Northamptonshire Police's request to investigate …
Essex Police
Peter Thompson
All Responded
Care home staff failed to perform routine blood sugar tests on a diabetic resident, delaying critical diagnosis. A lack of formal shift handovers also …
Bank Close House Residential …
David Dugdale
All Responded
Inadequate pain management, lack of nutritional support, and severe neglect of a pressure sore, exacerbated by nursing staff ignoring carers' concerns, led to significant …
East Sussex Healthcare NHS …
Jean Waldron
All Responded
An agency team leader disregarded clear instructions by providing inappropriate wound care, suggesting inadequate training on care limits and adherence to specialist medical advice …
Ignite Health and Homecare …
Drew Greaves-Pimblett
All Responded
National telephone triage pathways lack adequate guidance for call handlers on probing questions for critical symptoms like breathing and body temperature, hindering accurate assessment …
NHS England
Mohammed Choudhury
All Responded
Inadequate management of a patient's paranoid schizophrenia included failure to address non-concordance with anti-psychotic medication and withdrawal of medication support without GP checks, despite …
East London NHS Foundation …
Theo Tuikubulau
No Identified Response
Two distinct triage systems for 999 and 111 calls create a two-tiered ambulance categorisation for similar urgent breathing complications, potentially delaying critical responses based …
NHS England
Robert Gracey
Partially Responded
Despite national recommendations, Lincolnshire lacks an established protocol to treat suspected Acute Behavioural Disturbance (ABD) as a medical emergency. The NHS Pathways system also …
East Midlands Ambulance Service …
Lincolnshire Police
NHS England
Suzanne Pemberton
All Responded
The hospital lacks any specialist dietetic service outside weekday working hours, risking delays in crucial nutritional interventions like naso-gastric feeding and potential non-adherence to …
East Suffolk and North …
Adam Hussain
All Responded
The urgent care pathway poorly serves serious systemic illnesses like sepsis, with critical patient information not reliably used by ambulance staff, leading to unnotified …
East Midlands Ambulance Service …
NHS England
Nottingham and Nottinghamshire Integrated …