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 13 of 317
Showing 20 at a time
| Date | Report | Region / area | Addressee(s) | Status | Responses |
|---|---|---|---|---|---|
| 5 Dec 2025 |
Alan Peet
2025-0609
· Alison Mutch
A nurse untrained in tracheostomy management was allocated to a unit with high-needs patients, and an agency nurse lacked system login rights, …
|
North West
Manchester South
|
Acer Mews Care Home Care Quality Commission | No Identified Response | 0/2 |
| 5 Dec 2025 |
Andrew Hughes
2026-0099
· Alison Mutch
The 'Right Care Right Person' system lacks clarity on how concerned families can access emergency mental health services, and there is insufficient …
|
North West
Manchester South
|
Deputy Mayor of Greater Manchester Greater Manchester Integrated Care Board | All Responded | 3/2 |
| 5 Dec 2025 |
Leonardo Machado
2025-0611
· Brendan Allen
Insufficient oversight of 'rental' food delivery licenses to underage individuals places children in vulnerable lone working situations, increasing their risk of road …
|
South West
Dorset
|
Department for Business and Trade Department for Education Department for Transport Department for Work and Pensions | Partially Responded | 1/5 |
| 4 Dec 2025 |
Antonio Galisi-Swallow
2025-0608
· Oliver Longstaff
There is an absence of national guidance for the use of propofol for short-term sedation in children and young people in paediatric …
|
Yorkshire and the Humber
West Yorkshire Eastern
|
National Institute for Health and … Paediatric Critical Care Society National Clinical Director for Children … | All Responded | 1/3 |
| 4 Dec 2025 |
Samuel Brown
2025-0606
· Abigail Combes
The primary care prescribing regime failed to identify potential addiction and drug-seeking behaviour, and neglected to review medications for ongoing necessity.
|
Yorkshire and the Humber
South Yorkshire East
|
NHS South Yorkshire Integrated Care … | All Responded | 1/1 |
| 4 Dec 2025 |
Lina Piroli
2025-0607
· Melanie Lee
Elderly and complex patients, especially those with dementia, suffer detrimental delays in overcrowded A&E departments unequipped to provide specialist care, due to …
|
London
Inner North London
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 1 Dec 2025 |
Warren Green
2026-0011
· Jeane Mellani
High-risk self-harm patients could leave the acute ward without assessment or staff knowledge. The Mental Health Liaison Service lacks clear escalation criteria …
|
East of England
Essex
|
Essex Partnership University NHS Trust Mid & South Essex NHS … | All Responded | 2/2 |
| 1 Dec 2025 |
Mark Vidler
2026-0023
· Ian Potter
Mental health services suffered from process-driven care, unclear clinical decision-making in triaging referrals, and pre-determined discharge decisions lacking receiving team involvement. The …
|
South East
Kent and Medway
|
Kent and Medway NHS Mental … | All Responded | 1/1 |
| 1 Dec 2025 |
Stuart Berry
2026-0015
· Sean Horstead
Multiple failures by mental health services and serious deficiencies in prison suicide risk assessment, including poor ACCT completion, inadequate observations, and accessible …
|
East of England
Essex
|
Essex Partnership University NHS Foundation … HCRG HMPPS MoJ | Partially Responded | 2/4 |
| 1 Dec 2025 |
Abdullah Ali
2025-0604
· Melanie Lee
Extensive and thick black mould in the property managed by Granddwell Estates poses a significant risk of future deaths.
|
London
Inner North London
|
Granddwell Estates | All Responded | 1/1 |
| 1 Dec 2025 |
John Hickmott
2025-0605
· Adam Smith
Numerous streetlights on a dangerous stretch of road were reported faulty but not repaired in a timely manner, severely reducing pedestrian visibility …
|
South East
Milton Keynes
|
Highways and Transportation, Milton Keynes … | All Responded | 1/1 |
| 1 Dec 2025 |
Amy Pugh
2026-0013
· Paul Marks
Clinical staff could not access important mental health records from partner institutions, compromising the patient's assessment and subsequent management.
|
Yorkshire and the Humber
East Riding and Hull
|
NHS England | All Responded | 1/1 |
| 1 Dec 2025 |
Lewis Bates
2025-0602
· Chris Morris
Lack of guidance for 999 call handlers on 'reasonable enquiries' for missing persons and confusion with the 'Right Care Right Person' initiative …
|
North West
Manchester South
|
Greater Manchester Police | All Responded | 1/1 |
| 28 Nov 2025 |
Gurkirat Singh
2026-0089
· Zafar Siddique
A dangerous road stretch lacks pedestrian crossings, has obscured visibility from parked vehicles, and suffers from poor street lighting and absent central …
|
West Midlands
Black Country
|
Highways Department Sandwell Local Authority | Partially Responded | 1/2 |
| 27 Nov 2025 |
June Findlay
2025-0601
· Robert Simpson
Inadequate recognition, care planning, and monitoring of malnutrition risks by ward staff, who also failed to follow dietician advice. Auditing processes did …
|
South East
Berkshire
|
Frimley Health NHS Foundation Trust | All Responded | 1/1 |
| 26 Nov 2025 |
Evie Muir
2025-0600
· Stephen Simblet
Hospital reviews of unusual cardiac deaths are not sufficiently shared across specialties, and patients with cardiac and rheumatological conditions are inadequately assessed …
|
East of England
Essex
|
Mid and South Essex NHS … | All Responded | 1/1 |
| 26 Nov 2025 |
Evelyn Rae Le Masurier-O’Sullivan
2025-0597
· Sian Reeves
Midwifery staff failed to elicit and act upon parental concerns about a baby's breathing and crying during postnatal contacts, leading to missed …
|
London
South London
|
Crown Commercial Services NHS England | No Identified Response | 0/2 |
| 26 Nov 2025 |
Celia Phillips
2025-0598
· Ana Samuel
Carers for a bed-bound patient lacked understanding and training in preventing pressure sores, failing to perform crucial repositioning or properly assess skin, …
|
West Midlands
Birmingham and Solihull
|
Inspire You Care Ltd | All Responded | 1/1 |
| 26 Nov 2025 |
Aminata Coulibaly
2025-0596
· Sonia Hayes
Police failed to share critical self-harm information with mental health services and contact handlers inadequately recorded severe welfare concerns, hindering appropriate assessment …
|
East of England
Essex
|
Chief Constable of Essex Police | All Responded | 1/1 |
| 25 Nov 2025 |
Connor Nelson
2025-0603
· Elizabeth Didcock
Emergency staff showed no improved ability to respond to cardiac arrest. Medical staff lacked understanding of prolonged QTc syndrome and a robust …
|
East Midlands
Nottinghamshire
|
Sherwood Forest Hospitals NHS Foundation … | All Responded | 1/1 |
Alan Peet
No Identified Response
A nurse untrained in tracheostomy management was allocated to a unit with high-needs patients, and an agency nurse lacked system login rights, leading to …
Acer Mews Care Home
Care Quality Commission
Andrew Hughes
All Responded
The 'Right Care Right Person' system lacks clarity on how concerned families can access emergency mental health services, and there is insufficient provision for …
Deputy Mayor of Greater …
Greater Manchester Integrated Care …
Leonardo Machado
Partially Responded
Insufficient oversight of 'rental' food delivery licenses to underage individuals places children in vulnerable lone working situations, increasing their risk of road traffic collisions …
Department for Business and …
Department for Education
Department for Transport
Antonio Galisi-Swallow
All Responded
There is an absence of national guidance for the use of propofol for short-term sedation in children and young people in paediatric intensive care …
National Institute for Health …
Paediatric Critical Care Society
National Clinical Director for …
Samuel Brown
All Responded
The primary care prescribing regime failed to identify potential addiction and drug-seeking behaviour, and neglected to review medications for ongoing necessity.
NHS South Yorkshire Integrated …
Lina Piroli
All Responded
Elderly and complex patients, especially those with dementia, suffer detrimental delays in overcrowded A&E departments unequipped to provide specialist care, due to a lack …
Department of Health and …
NHS England
Warren Green
All Responded
High-risk self-harm patients could leave the acute ward without assessment or staff knowledge. The Mental Health Liaison Service lacks clear escalation criteria to consultants, …
Essex Partnership University NHS …
Mid & South Essex …
Mark Vidler
All Responded
Mental health services suffered from process-driven care, unclear clinical decision-making in triaging referrals, and pre-determined discharge decisions lacking receiving team involvement. The CAMS program …
Kent and Medway NHS …
Stuart Berry
Partially Responded
Multiple failures by mental health services and serious deficiencies in prison suicide risk assessment, including poor ACCT completion, inadequate observations, and accessible ligature points, …
Essex Partnership University NHS …
HCRG
HMPPS
Abdullah Ali
All Responded
Extensive and thick black mould in the property managed by Granddwell Estates poses a significant risk of future deaths.
Granddwell Estates
John Hickmott
All Responded
Numerous streetlights on a dangerous stretch of road were reported faulty but not repaired in a timely manner, severely reducing pedestrian visibility and contributing …
Highways and Transportation, Milton …
Amy Pugh
All Responded
Clinical staff could not access important mental health records from partner institutions, compromising the patient's assessment and subsequent management.
NHS England
Lewis Bates
All Responded
Lack of guidance for 999 call handlers on 'reasonable enquiries' for missing persons and confusion with the 'Right Care Right Person' initiative led to …
Greater Manchester Police
Gurkirat Singh
Partially Responded
A dangerous road stretch lacks pedestrian crossings, has obscured visibility from parked vehicles, and suffers from poor street lighting and absent central road markings, …
Highways Department
Sandwell Local Authority
June Findlay
All Responded
Inadequate recognition, care planning, and monitoring of malnutrition risks by ward staff, who also failed to follow dietician advice. Auditing processes did not identify …
Frimley Health NHS Foundation …
Evie Muir
All Responded
Hospital reviews of unusual cardiac deaths are not sufficiently shared across specialties, and patients with cardiac and rheumatological conditions are inadequately assessed for associated …
Mid and South Essex …
Evelyn Rae Le Masurier-O’Sullivan
No Identified Response
Midwifery staff failed to elicit and act upon parental concerns about a baby's breathing and crying during postnatal contacts, leading to missed neonatal assessments …
Crown Commercial Services
NHS England
Celia Phillips
All Responded
Carers for a bed-bound patient lacked understanding and training in preventing pressure sores, failing to perform crucial repositioning or properly assess skin, despite documented …
Inspire You Care Ltd
Aminata Coulibaly
All Responded
Police failed to share critical self-harm information with mental health services and contact handlers inadequately recorded severe welfare concerns, hindering appropriate assessment and response.
Chief Constable of Essex …
Connor Nelson
All Responded
Emergency staff showed no improved ability to respond to cardiac arrest. Medical staff lacked understanding of prolonged QTc syndrome and a robust process for …
Sherwood Forest Hospitals NHS …