Prevention of Future Deaths Reports

Judiciary

Browse 6,327 coroners' Regulation 28 reports by year, region, organisation, category, or keyword.

Data sourced from judiciary.uk under the Open Government Licence.

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6,327 reports · Page 12 of 317
Showing 20 at a time
Date Report Region / area Addressee(s) Status Responses
16 Dec 2025 Richard Haddock
2025-0627 · Alison Longhorn
Police processes failed to notify the Firearms Licensing Department of a prosecution, and the department did not check PNC records, leading to …
South West
County of Devon, Plymouth and Torbay
 Devon & Cornwall Police All Responded 1/1
16 Dec 2025 Philip Hoggarth
2025-0628 · Caroline Saunders
A lack of consistent guidelines and processes for pre-operative iron administration to chronically anaemic patients, alongside no funding agreement, risks damaging delays …
Wales
Gwent
 Aneurin Bevan University Health Board All Responded 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 All Responded 1/1
Unknown Syeda Fatima
2025-0613 · Adam Hodson
Significant and systemic cultural tensions, including hierarchy and bullying, between midwifery and obstetric staff contributed to critical delays in patient care and …
West Midlands
Birmingham and Solihull
 University Hospitals Birmingham NHS Foundation … All Responded 1/1
Unknown Man Ng
2025-0614 · Richard Brittain
Complex and non-streamlined processes for subarachnoid haemorrhage treatment, compounded by neurointerventionalists lacking admitting rights, create unclear overall clinical responsibility and risk patient …
West Midlands
Coventry
 [REDACTED] President of The Royal … [REDACTED], President of The Royal … [REDACTED] President of The Royal … All Responded 3/3
15 Dec 2025 Anthony Lodge
2025-0669 · Rebecca Sutton
Urine sample bottles lacked expiry dates, resulting in the use of out-of-date containers and subsequent delays in laboratory processing, posing a risk …
North East
County Durham and Darlington
 Internation Scientific Supplies Ltd All Responded 1/1
15 Dec 2025 Lee Eustace
2025-0626 · Louise Wiltshire
An insufficient feeding protocol likely contributed to death, compounded by failures to raise a Datix, send a Duty of Candour letter, and …
South West
County of Devon, Plymouth and Torbay
 University Hospitals Plymouth NHS Trust All Responded 1/1
15 Dec 2025 Sundeep Ghuman
2025-0625 · David Manknell
Systemic misunderstanding of the CSRA policy for prisoners posing racist risks led to incorrect 'standard risk' categorization instead of 'high risk,' reflecting …
London
London Inner South
 HMP Belmarsh Ministry of Justice Partially Responded 1/2
Unknown Dominic Philip
2025-0617 · Hassan Shah
The hospital lacked pre-screening for contrast allergies, and Lidocaine was inexplicably present in an allergic patient, raising concerns about medication contamination or …
East Midlands
Northamptonshire
 Medicines and Healthcare Products Regulatory … Royal College of Radiologists Department of Health and Social … University Hospitals of Northamptonshire NHS … All Responded 4/4
Unknown John Alston
2025-0616 · Kate Bisset
Confusion and delays in identifying the correct Integrated Care Board (ICB) responsible for commissioning a patient's care led to delays in accessing …
North West
Lancashire and Blackburn with Darwen
 NHS England All Responded 1/1
Unknown Hannah Booth
2025-0615 · Susan Evans
Fragmented IT systems and poor information sharing between and within services meant crucial mental health information about the mother was not readily …
East Midlands
Derby and Derbyshire
 Derbyshire Community Health Services NHS … Derbyshire Healthcare NHS Foundation Trust NHS Derby & Derbyshire Integrated … NHS England All Responded 5/5
11 Dec 2025 Ashana Charles
2025-0620 · Andrew Harris
Critical medical equipment was not retained for forensic investigation, and there is inconsistent national guidance on parenteral nutrition filters, alongside fragmented risk …
London
South London
 NHSE NHS England [REDACTED], Chief Executive, Medicines and … [REDACTED], Chief National Medical Examiner, … Partially Responded 1/4
11 Dec 2025 Katherine Wright
2025-0624 · Nicholas Graham
Police lack structured training and clear guidance for conducting adequate searches in missing person cases, and there are no protocols for officers …
South East
Oxfordshire
 Thames Valley Police All Responded 1/1
11 Dec 2025 Izzah Ali
2025-0622 · Andrew Cox
The 'Essential Guide to feeding your Baby' is inadequate as it fails to explicitly warn against giving cow's milk to infants under …
South West
Cornwall and the Isles of Scilly
 Education and Children’s Community Health No Identified Response 0/1
11 Dec 2025 Izzah Ali
2025-0623 · Andrew Cox
Healthcare professionals failed to inquire about the contents of 'bottle-fed' milk and did not use interpreters for a non-English speaking mother, reflecting …
South West
Cornwall and the Isles of Scilly
 Cornwall Council Cornwall Partnership NHS Foundation Trust ICB Royal Cornwall Hospital All Responded 3/4
11 Dec 2025 David Langford
2025-0621 · Kate Robertson
Poor visibility at a dangerous road junction, caused by overgrown foliage, a dull mirror, and old railings, is exacerbated by an inappropriate …
Wales
North Wales (East and Central)
 Conwy County Borough Council Road (Highways Safety) related deaths Wales prevention of future deaths … Partially Responded 1/3
10 Dec 2025 Mesut Olgun
2025-0618 · David Reid
West Midlands
Worcestershire
 HM Prison and Probation Service Probation and Reducing Offending, Ministry … All Responded 1/2
9 Dec 2025 Urielle Kuyenga
2025-0635 · Graeme Irvine
A critical communication breakdown between hospital and GP regarding medication monitoring, combined with repeated failures by GPs to check clinical records, left …
London
East London
 Barts Health NHS Trust Department of Health and Social … East London Cooperatives Ltd Maylands Healthcare Surgery All Responded 4/4
8 Dec 2025 Matilda Seccombe and Harry Purcell
2025-0612 · Linda Lee
Current licensing arrangements for new drivers inadequately address risks from multiple passengers, vehicle loading, and rural road conditions. Insurers also lack consistent …
West Midlands
Coventry and Warwickshire
 Association of British Insurers Brake Chartered Insurance Institute Department for Transport Partially Responded 5/7
8 Dec 2025 Oliver Mulangala
2025-0610 · Jonathan Stevens
The pervasive availability of illicit drugs, particularly new psychoactive substances, and mobile phones in HMP High Down leads to widespread misuse, coercion, …
South East
Surrey
 HMP High Down HMPPS Ministry of Justice The Minister of State for … Partially Responded 1/4
Richard Haddock All Responded
16 Dec 2025 South West 1/1 responses
Police processes failed to notify the Firearms Licensing Department of a prosecution, and the department did not check PNC records, leading to a shotgun …
Devon & Cornwall Police
Philip Hoggarth All Responded
16 Dec 2025 Wales 1/1 responses
A lack of consistent guidelines and processes for pre-operative iron administration to chronically anaemic patients, alongside no funding agreement, risks damaging delays in surgery.
Aneurin Bevan University Health …
Walter Pollyn All Responded
16 Dec 2025 South East 1/1 responses
Nursing staff repeatedly failed to adhere to 'nil by mouth' instructions despite clear documentation and visual cues, indicating potential underlying attitudinal issues and inadequate …
Medway NHS Foundation Trust
Syeda Fatima All Responded
West Midlands 1/1 responses
Significant and systemic cultural tensions, including hierarchy and bullying, between midwifery and obstetric staff contributed to critical delays in patient care and decision-making.
University Hospitals Birmingham NHS …
Man Ng All Responded
West Midlands 3/3 responses
Complex and non-streamlined processes for subarachnoid haemorrhage treatment, compounded by neurointerventionalists lacking admitting rights, create unclear overall clinical responsibility and risk patient safety.
[REDACTED] President of The … [REDACTED], President of The … [REDACTED] President of The …
Anthony Lodge All Responded
15 Dec 2025 North East 1/1 responses
Urine sample bottles lacked expiry dates, resulting in the use of out-of-date containers and subsequent delays in laboratory processing, posing a risk of future …
Internation Scientific Supplies Ltd
Lee Eustace All Responded
15 Dec 2025 South West 1/1 responses
An insufficient feeding protocol likely contributed to death, compounded by failures to raise a Datix, send a Duty of Candour letter, and disclose critical …
University Hospitals Plymouth NHS …
Sundeep Ghuman Partially Responded
15 Dec 2025 London 1/2 responses
Systemic misunderstanding of the CSRA policy for prisoners posing racist risks led to incorrect 'standard risk' categorization instead of 'high risk,' reflecting a significant …
HMP Belmarsh Ministry of Justice
Dominic Philip All Responded
East Midlands 4/4 responses
The hospital lacked pre-screening for contrast allergies, and Lidocaine was inexplicably present in an allergic patient, raising concerns about medication contamination or poor stock …
Medicines and Healthcare Products … Royal College of Radiologists Department of Health and …
John Alston All Responded
North West 1/1 responses
Confusion and delays in identifying the correct Integrated Care Board (ICB) responsible for commissioning a patient's care led to delays in accessing appropriate support …
NHS England
Hannah Booth All Responded
East Midlands 5/5 responses
Fragmented IT systems and poor information sharing between and within services meant crucial mental health information about the mother was not readily accessible or …
Derbyshire Community Health Services … Derbyshire Healthcare NHS Foundation … NHS Derby & Derbyshire …
Ashana Charles Partially Responded
11 Dec 2025 London 1/4 responses
Critical medical equipment was not retained for forensic investigation, and there is inconsistent national guidance on parenteral nutrition filters, alongside fragmented risk management between …
NHSE NHS England [REDACTED], Chief Executive, Medicines …
Katherine Wright All Responded
11 Dec 2025 South East 1/1 responses
Police lack structured training and clear guidance for conducting adequate searches in missing person cases, and there are no protocols for officers to escalate …
Thames Valley Police
Izzah Ali No Identified Response
11 Dec 2025 South West 0/1 responses
The 'Essential Guide to feeding your Baby' is inadequate as it fails to explicitly warn against giving cow's milk to infants under one year …
Education and Children’s Community …
Izzah Ali All Responded
11 Dec 2025 South West 3/4 responses
Healthcare professionals failed to inquire about the contents of 'bottle-fed' milk and did not use interpreters for a non-English speaking mother, reflecting a lack …
Cornwall Council Cornwall Partnership NHS Foundation … ICB
David Langford Partially Responded
11 Dec 2025 Wales 1/3 responses
Poor visibility at a dangerous road junction, caused by overgrown foliage, a dull mirror, and old railings, is exacerbated by an inappropriate national speed …
Conwy County Borough Council Road (Highways Safety) related … Wales prevention of future …
Mesut Olgun All Responded
10 Dec 2025 West Midlands 1/2 responses
HM Prison and Probation … Probation and Reducing Offending, …
Urielle Kuyenga All Responded
9 Dec 2025 London 4/4 responses
A critical communication breakdown between hospital and GP regarding medication monitoring, combined with repeated failures by GPs to check clinical records, left a child …
Barts Health NHS Trust Department of Health and … East London Cooperatives Ltd
Matilda Seccombe and Harry Purcell Partially Responded
8 Dec 2025 West Midlands 5/7 responses
Current licensing arrangements for new drivers inadequately address risks from multiple passengers, vehicle loading, and rural road conditions. Insurers also lack consistent methods to …
Association of British Insurers Brake Chartered Insurance Institute
Oliver Mulangala Partially Responded
8 Dec 2025 South East 1/4 responses
The pervasive availability of illicit drugs, particularly new psychoactive substances, and mobile phones in HMP High Down leads to widespread misuse, coercion, and severe …
HMP High Down HMPPS Ministry of Justice