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 14 of 317
Showing 20 at a time
| Date | Report | Region / area | Addressee(s) | Status | Responses |
|---|---|---|---|---|---|
| 25 Nov 2025 |
Benedict Blythe
2025-0595
· Elizabeth Gray
Pathology protocols for suspected anaphylaxis need revision to ensure appropriate sample collection and retention. Police investigations of unexplained child deaths also lack …
|
East of England
Cambridgeshire and Peterborough
|
Cambridgeshire Constabulary Royal College of Pathologists | All Responded | 2/2 |
| 25 Nov 2025 |
Andrew McCleary
2025-0599
· Emma Whitting
Police officers lacked knowledge of Mental Capacity Act requirements for restraint, awareness of restraint risks, and failed to collaborate with ambulance staff …
|
East of England
Bedfordshire and Luton
|
Bedfordshire Police | All Responded | 1/1 |
| 24 Nov 2025 |
Diana Grant
2025-0594
· Richard Travers
Critically ill mental health patients needing secure admission, especially if dangerous, face unavoidable prolonged detention in prison due to restricted unit capacity, …
|
South East
Surrey
|
[REDACTED] CEO, NHS England [REDACTED] The Secretary of State … | All Responded | 2/2 |
| 21 Nov 2025 |
Timothy Reading
2026-0101
· James Puzey
The lack of formal, agreed S.117 plans for mental health discharge creates disjointed patient support. There is also no national guidance clarifying …
|
West Midlands
Worcestershire
|
Birmingham and Solihull Mental Health … NHS England | All Responded | 2/2 |
| 20 Nov 2025 |
Lisa Bowen
2025-0592
· Richard Travers
A vehicle's anti-locking braking system (ABS) critically failed after a tyre detachment, incorrectly reducing braking and creating an unaddressed design flaw. This …
|
South East
Surrey
|
Department for Business and Trade Department for Transport Driver and Vehicle Standards Agency Toyota Motor Corporation | All Responded | 2/6 |
| 19 Nov 2025 |
Anna Burns
2026-0127
· Grant Davies
The methadone prescribing agency was unaware of the patient's prior opioid overdose and hospital admission because discharge summaries were not shared with …
|
South West
Wiltshire and Swindon
|
Great Western Hospital | No Identified Response | 0/1 |
| 18 Nov 2025 |
Derrion Adams
2025-0586
· Emma Brown
Contraband and novel psychoactive substances continue to enter the prison, posing a risk to life and burdening staff during unpredictable "spikes" in …
|
West Midlands
Birmingham and Solihull
|
HM Prison and Probation Service | All Responded | 1/1 |
| 18 Nov 2025 |
Jack Brown
2025-0593
· Sophie Lomas
Unregulated care agencies provide staff to care homes without oversight of recruitment or training, risking vulnerable residents being cared for by unsuitable …
|
East Midlands
Northamptonshire
|
Department of Health and Social … | All Responded | 1/1 |
| 18 Nov 2025 |
Dominic Hurley
2025-0588
· Penelope Schofield
The system for renewing diving licenses relies too heavily on self-declaration, failing to verify previous medical history or diving incidents, which risks …
|
South East
West Sussex, Brighton and Hove
|
British Sub Aqua Association Sub Aqua Association Spcae Solutions … | All Responded | 1/2 |
| 18 Nov 2025 |
Lynsey Dearden
2025-0589
· Emma Serrano
A patient allocated community mental health support received no appointments for months. Critically, there was no policy or framework guiding the timing …
|
West Midlands
Staffordshire and Stoke on Trent
|
NHS England North Staffordshire Combined Healthcare NHS … | All Responded | 2/2 |
| 18 Nov 2025 |
Steven Ruddick
2025-0591
· Crispin Oliver
Procedural differences in observing detained persons during toilet visits between police and GeoAmey custody created an opportunity for prohibited items to be …
|
North East
County Durham and Darlington
|
GeoAmey HM Prison Service | Partially Responded | 1/2 |
| 17 Nov 2025 |
Thomas Morrell
2025-0583
· Thomas Crookes
Failure to promptly recognise heart failure and the absence of a HOCM patient referral SOP delayed specialist transfer. A lack of regular …
|
North East
Newcastle and North Tyneside
|
York and Scarborough Teaching Hospitals … | All Responded | 1/1 |
| 17 Nov 2025 |
Andrew Dodds
2025-0587
· Marilyn Whittle
Police failed to provide next of kin details to the s136 suite and crucial information about prior s136 detention was missing from …
|
Yorkshire and the Humber
South Yorkshire West
|
South Yorkshire Police Headquaters | All Responded | 1/1 |
| 17 Nov 2025 |
Paolino Amico
2025-0585
· Sonia Hayes
Multiple serious medication errors, including non-administration of pain relief and prescription mistakes, occurred. There were also critical failures in the discharge plan …
|
East of England
Essex
|
NHS England Princess Aleandra Hospital | All Responded | 2/2 |
| 17 Nov 2025 |
Ethel Robertson
2025-0584
· Nicholas Walker
A critical communication gap exists as the Older People’s Mental Health Service is not routinely informed of their patients' ED admissions for …
|
South East
Hampshire, Portsmouth and Southampton
|
Southern Health Foundation Trust | All Responded | 1/1 |
| 14 Nov 2025 |
Suzanne Ellerby
2025-0582
· Anna Loxton
A lack of universal safety netting guidelines for transferring vulnerable mental health patients from secondary to primary care leaves patients unsupported, leading …
|
South East
Surrey
|
[REDACTED], Chief Executive Officer, NHS … [REDACTED], Parliamentary Under-Secretary for Patient … | All Responded | 2/2 |
| 14 Nov 2025 |
Margaret Crooks
2025-0581
· Alison Mutch
Confusion among stroke clinicians about the level of overnight expert support available led to delays in time-critical advice for stroke complications, potentially …
|
North West
Manchester South
|
Greater Manchester Integrated Care | All Responded | 1/1 |
| 14 Nov 2025 |
Ronald Perry
2025-0580
· Alison Mutch
Poor documentation, incomplete falls risk assessments, and staff misunderstanding of the falls policy for anticoagulated patients led to inadequate care and missed …
|
North West
Manchester South
|
Lakes Care Centre | All Responded | 1/1 |
| 12 Nov 2025 |
Barry Loxston
2025-0573
· Fiona Wilcox
Serious failures pre-surgery included not recognising unfitness for transplant. Post-operatively, critically low potassium was untreated due to workload, and nursing care lacked …
|
London
Inner West London
|
St George’s University Hospitals | No Identified Response | 0/1 |
| 12 Nov 2025 |
Christopher Sampson
2025-0572
· Adam Hodson
Drivers are failing to self-notify the DVLA of medical conditions, and there's a lack of clarity on medical professionals' awareness or effective …
|
West Midlands
Birmingham and Solihull
|
Department for Transport DVLA General Medical Council General Optical Council | All Responded | 3/4 |
Benedict Blythe
All Responded
Pathology protocols for suspected anaphylaxis need revision to ensure appropriate sample collection and retention. Police investigations of unexplained child deaths also lack procedures for …
Cambridgeshire Constabulary
Royal College of Pathologists
Andrew McCleary
All Responded
Police officers lacked knowledge of Mental Capacity Act requirements for restraint, awareness of restraint risks, and failed to collaborate with ambulance staff or monitor …
Bedfordshire Police
Diana Grant
All Responded
Critically ill mental health patients needing secure admission, especially if dangerous, face unavoidable prolonged detention in prison due to restricted unit capacity, where their …
[REDACTED] CEO, NHS England
[REDACTED] The Secretary of …
Timothy Reading
All Responded
The lack of formal, agreed S.117 plans for mental health discharge creates disjointed patient support. There is also no national guidance clarifying the required …
Birmingham and Solihull Mental …
NHS England
Lisa Bowen
All Responded
A vehicle's anti-locking braking system (ABS) critically failed after a tyre detachment, incorrectly reducing braking and creating an unaddressed design flaw. This specific scenario …
Department for Business and …
Department for Transport
Driver and Vehicle Standards …
Anna Burns
No Identified Response
The methadone prescribing agency was unaware of the patient's prior opioid overdose and hospital admission because discharge summaries were not shared with them. This …
Great Western Hospital
Derrion Adams
All Responded
Contraband and novel psychoactive substances continue to enter the prison, posing a risk to life and burdening staff during unpredictable "spikes" in incidents. Current …
HM Prison and Probation …
Jack Brown
All Responded
Unregulated care agencies provide staff to care homes without oversight of recruitment or training, risking vulnerable residents being cared for by unsuitable individuals lacking …
Department of Health and …
Dominic Hurley
All Responded
The system for renewing diving licenses relies too heavily on self-declaration, failing to verify previous medical history or diving incidents, which risks diver safety.
British Sub Aqua Association
Sub Aqua Association Spcae …
Lynsey Dearden
All Responded
A patient allocated community mental health support received no appointments for months. Critically, there was no policy or framework guiding the timing or process …
NHS England
North Staffordshire Combined Healthcare …
Steven Ruddick
Partially Responded
Procedural differences in observing detained persons during toilet visits between police and GeoAmey custody created an opportunity for prohibited items to be hidden. The …
GeoAmey
HM Prison Service
Thomas Morrell
All Responded
Failure to promptly recognise heart failure and the absence of a HOCM patient referral SOP delayed specialist transfer. A lack of regular cardiac monitoring …
York and Scarborough Teaching …
Andrew Dodds
All Responded
Police failed to provide next of kin details to the s136 suite and crucial information about prior s136 detention was missing from police systems, …
South Yorkshire Police Headquaters
Paolino Amico
All Responded
Multiple serious medication errors, including non-administration of pain relief and prescription mistakes, occurred. There were also critical failures in the discharge plan for oxygen …
NHS England
Princess Aleandra Hospital
Ethel Robertson
All Responded
A critical communication gap exists as the Older People’s Mental Health Service is not routinely informed of their patients' ED admissions for non-mental health …
Southern Health Foundation Trust
Suzanne Ellerby
All Responded
A lack of universal safety netting guidelines for transferring vulnerable mental health patients from secondary to primary care leaves patients unsupported, leading to gaps …
[REDACTED], Chief Executive Officer, …
[REDACTED], Parliamentary Under-Secretary for …
Margaret Crooks
All Responded
Confusion among stroke clinicians about the level of overnight expert support available led to delays in time-critical advice for stroke complications, potentially affecting patient …
Greater Manchester Integrated Care
Ronald Perry
All Responded
Poor documentation, incomplete falls risk assessments, and staff misunderstanding of the falls policy for anticoagulated patients led to inadequate care and missed medical advice.
Lakes Care Centre
Barry Loxston
No Identified Response
Serious failures pre-surgery included not recognising unfitness for transplant. Post-operatively, critically low potassium was untreated due to workload, and nursing care lacked proper manual …
St George’s University Hospitals
Christopher Sampson
All Responded
Drivers are failing to self-notify the DVLA of medical conditions, and there's a lack of clarity on medical professionals' awareness or effective use of …
Department for Transport
DVLA
General Medical Council