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 11 of 317
Showing 20 at a time
| Date | Report | Region / area | Addressee(s) | Status | Responses |
|---|---|---|---|---|---|
| 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 |
| 4 Jan 2026 |
Lajos Mandrik
2026-0219
· Richard Furniss
Observations on Ellis Ward may not be carried out in accordance with Trust policy, with staff not always attempting to engage with …
|
London
West London
|
South West London and St … | Response Pending | 0/1 |
| 29 Dec 2025 |
Fallon Adams
2025-0647
· Simon Milburn
There was a failure to provide specific warnings to the prisoner about the dangers of combining prescribed sedative medications with illicit drugs, …
|
East of England
Cambridgeshire and Peterborough
|
Northamptonshire Healthcare Foundation Trust | All Responded | 1/1 |
| 29 Dec 2025 |
Brian Mitchell
2025-0645
· Graeme Irvine
No clear evidence exists that risks of fatal harm on railway tracks have been mitigated, with recommended detection technology unimplemented and training …
|
London
East London
|
Department for Transport Mayor of London Transport for London | No Identified Response | 0/3 |
| 28 Dec 2025 |
Mohamed Abdisamad
2025-0644
· Anton van Dellen
There is a complete absence of regulation for Non-Therapeutic Male Circumcisions, including no requirements for training, accreditation, consent, record-keeping, infection control, or …
|
London
West London
|
Department for Health and Social … | All Responded | 2/1 |
| 24 Dec 2025 |
Alan Baker
2025-0643
· Johanna Thompson
There is no mandatory requirement for LGVs to have reversing cameras or for existing cameras to be maintained, increasing the risk of …
|
East of England
Norfolk
|
Driver and Vehicle Standards Agency | All Responded | 1/1 |
| 23 Dec 2025 |
Colin Brown
2025-0642
· Gillian Kane
Crucial patient information, such as choking risk, was not reliably transferred with the patient or consistently communicated during hospital handovers, compounded by …
|
Yorkshire and the Humber
North Yorkshire and York
|
York Hospital YAS Legal | All Responded | 2/2 |
| 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 …
|
East Midlands
Northamptonshire
|
Northampton General Hospital | All Responded | 1/1 |
| 22 Dec 2025 |
Wendy Eyles
2025-0641
· Hassan Shah
No protocol exists for managing patients under both NHS and private psychiatry, leading to critical medication changes not being communicated, creating confusion …
|
East Midlands
Northamptonshire
|
Northamptonshire Healthcare Foundation Trust Northamptonshire Integrated Care Board | No Identified Response | 0/2 |
| 22 Dec 2025 |
Winifred Wardle
2025-0640
· Adrian Farrow
The hospital lacks a clear multi-disciplinary protocol for CT scan requests, with unclear escalation lines when requests are rejected and inadequate record-keeping …
|
North West
Manchester South
|
Tameside and Glossop Integrated Care … | No Identified Response | 0/1 |
| 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 | All Responded | 1/2 |
| 19 Dec 2025 |
Ramona Harbott
2025-0637
· Susan Ridge
Care home staff failed to adhere to pressure sore prevention policies, leading to inadequate repositioning, poor skin monitoring, and severe, undocumented pressure …
|
South East
Surrey
|
Care Quality Commission, Barchester Health … | All Responded | 2/1 |
| 19 Dec 2025 |
Jason White
2025-0638
· N Mundy
Antipsychotic medication was abruptly ceased, and the daily monitoring plan was not followed, creating an unmanaged risk of relapse and serious deterioration …
|
Yorkshire and the Humber
South Yorkshire East
|
Sheffield Health Partnership, University NHS … | All Responded | 1/1 |
| 18 Dec 2025 |
Stephen Page
2026-0046
· Ian Potter
The electronic sensor system provides only a brief, visual CCTV alert without an audible alarm, making it easily missed by operators and …
|
South East
Kent and Medway
|
MAPP Hempstead Valley Shopping Centre MAPP | Partially Responded | 1/3 |
| 18 Dec 2025 |
John Oates
2025-0646
· Kirsty Gomersal
Manufacturing defects in widespread porcelain tension disc insulators cause failures that can lead to dangerous low-hanging power lines, a risk compounded by …
|
North West
Cumbria
|
Electricity Networks Association | All Responded | 1/1 |
| 18 Dec 2025 |
Edward Jones
2025-0633
· Oliver Longstaff
The absence of a nationally validated sepsis screening tool for Paediatric Emergency Departments and inconsistent application of the trust's own tool across …
|
Yorkshire and the Humber
West Yorkshire Eastern
|
National Institute for Health and … | All Responded | 1/1 |
| 17 Dec 2025 |
Anthony Binfield
2025-0080
· Laurinda Bower
A dangerous prison culture of delaying cell entry when observation panels are obscured, assuming privacy rather than self-harm risk, persists despite repeated …
|
East Midlands
Nottingham City and Nottinghamshire
|
HMP Lowdham Grange | All Responded | 1/1 |
| 17 Dec 2025 |
Debapriya Ghosh and David Ward
2025-0634
· Fiona Wilcox
Insufficient staffing and bed spaces in A&E resulted in frail elderly patients being unsupervised, leading to unwitnessed falls, fatal head injuries, and …
|
London
Inner West London
|
Department of Health and Social … | All Responded | 1/1 |
| 17 Dec 2025 |
Dorothy Macdonald
2025-0632
· David Lewis
Nursing home staff repeatedly and incorrectly assessed a vulnerable patient's falls risk as low, indicating ineffective training in risk assessment and a …
|
North West
Liverpool and Wirral
|
Westwood Hall Nursing Home | All Responded | 1/1 |
| 17 Dec 2025 |
Valerie Gibson
2025-0630
· David Place
Staff confusion regarding medication dispensing and administration, inadequate checking of patient possessions, and inconsistent electronic record-keeping posed risks of over/under medication and …
|
North East
Sunderland
|
Cumbria, Northumberland, Tyne and Wear … | All Responded | 1/1 |
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 …
Lajos Mandrik
Response Pending
Observations on Ellis Ward may not be carried out in accordance with Trust policy, with staff not always attempting to engage with patients during …
South West London and …
Fallon Adams
All Responded
There was a failure to provide specific warnings to the prisoner about the dangers of combining prescribed sedative medications with illicit drugs, which can …
Northamptonshire Healthcare Foundation Trust
Brian Mitchell
No Identified Response
No clear evidence exists that risks of fatal harm on railway tracks have been mitigated, with recommended detection technology unimplemented and training effectiveness for …
Department for Transport
Mayor of London
Transport for London
Mohamed Abdisamad
All Responded
There is a complete absence of regulation for Non-Therapeutic Male Circumcisions, including no requirements for training, accreditation, consent, record-keeping, infection control, or crucial aftercare.
Department for Health and …
Alan Baker
All Responded
There is no mandatory requirement for LGVs to have reversing cameras or for existing cameras to be maintained, increasing the risk of accidents during …
Driver and Vehicle Standards …
Colin Brown
All Responded
Crucial patient information, such as choking risk, was not reliably transferred with the patient or consistently communicated during hospital handovers, compounded by delays in …
York Hospital
YAS Legal
Elaine Griffiths
All Responded
Inconsistent and partially completed fluid/diet charts, confusion regarding dietary intolerances, limited suitable food options, and unrecorded external food intake hindered accurate nutritional monitoring.
Northampton General Hospital
Wendy Eyles
No Identified Response
No protocol exists for managing patients under both NHS and private psychiatry, leading to critical medication changes not being communicated, creating confusion and patient …
Northamptonshire Healthcare Foundation Trust
Northamptonshire Integrated Care Board
Winifred Wardle
No Identified Response
The hospital lacks a clear multi-disciplinary protocol for CT scan requests, with unclear escalation lines when requests are rejected and inadequate record-keeping of decision-making …
Tameside and Glossop Integrated …
Wendy Eyles
All Responded
A lack of protocol for patients receiving both NHS and private psychiatric care leads to poor communication regarding medication changes, risking patient safety due …
Northamptonshire Healthcare NHS Foundation …
Northamptonshire Integrated Care Board
Ramona Harbott
All Responded
Care home staff failed to adhere to pressure sore prevention policies, leading to inadequate repositioning, poor skin monitoring, and severe, undocumented pressure sores for …
Care Quality Commission, Barchester …
Jason White
All Responded
Antipsychotic medication was abruptly ceased, and the daily monitoring plan was not followed, creating an unmanaged risk of relapse and serious deterioration in the …
Sheffield Health Partnership, University …
Stephen Page
Partially Responded
The electronic sensor system provides only a brief, visual CCTV alert without an audible alarm, making it easily missed by operators and risking lost …
MAPP
Hempstead Valley Shopping Centre
MAPP
John Oates
All Responded
Manufacturing defects in widespread porcelain tension disc insulators cause failures that can lead to dangerous low-hanging power lines, a risk compounded by insufficient adoption …
Electricity Networks Association
Edward Jones
All Responded
The absence of a nationally validated sepsis screening tool for Paediatric Emergency Departments and inconsistent application of the trust's own tool across units risk …
National Institute for Health …
Anthony Binfield
All Responded
A dangerous prison culture of delaying cell entry when observation panels are obscured, assuming privacy rather than self-harm risk, persists despite repeated policy reminders …
HMP Lowdham Grange
Debapriya Ghosh and David Ward
All Responded
Insufficient staffing and bed spaces in A&E resulted in frail elderly patients being unsupervised, leading to unwitnessed falls, fatal head injuries, and a failure …
Department of Health and …
Dorothy Macdonald
All Responded
Nursing home staff repeatedly and incorrectly assessed a vulnerable patient's falls risk as low, indicating ineffective training in risk assessment and a failure to …
Westwood Hall Nursing Home
Valerie Gibson
All Responded
Staff confusion regarding medication dispensing and administration, inadequate checking of patient possessions, and inconsistent electronic record-keeping posed risks of over/under medication and patient harm.
Cumbria, Northumberland, Tyne and …