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 15 of 317
Showing 20 at a time
| Date | Report | Region / area | Addressee(s) | Status | Responses |
|---|---|---|---|---|---|
| 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 |
| 11 Nov 2025 |
Joan Talbot
2025-0569
· Liliane Field
Due to a lack of continuity across different admitting teams, the significance of a patient's repeated symptoms was not fully appreciated, delaying …
|
London
Inner South London
|
[REDACTED], Chief Executive Officer, King’s … | All Responded | 1/1 |
| 11 Nov 2025 |
Liliane Bowden
2025-0570
· Henry Charles
Significant ambulance delays, caused by high demand and prolonged hospital handovers, led to extended waits for Category 3 calls. This poses a …
|
South East
Hampshire, Portsmouth and Southampton
|
SCAS Legal Services | All Responded | 1/1 |
| 11 Nov 2025 |
Tracey Oldfield
2025-0578
· Andrew Cox
Delayed prescription of usual medications for late-admitted patients leads to inappropriate alternative pain relief. The process for timely medication prescription for such …
|
South West
Cornwall and the Isles of Scilly
|
Royal Cornwall Hospital | All Responded | 1/1 |
| 10 Nov 2025 |
Costas Chrysostomou
2026-0177
· Ian Potter
There is potential for confusion due to differing interpretations of the term 'urgent' in cardiology pathways, and a lack of clarity among …
|
London
Inner North London
|
NHS North Central London Integrated … | All Responded | 1/1 |
| 10 Nov 2025 |
Jacqueline Aarons
2025-0576
· Andrew Walker
A lower hospital admission threshold for patients with learning disabilities is required. Furthermore, doctor's discharge instructions and safety netting advice for non-medical …
|
London
North London
|
Department of Health and Social … | All Responded | 1/1 |
| 10 Nov 2025 |
Alan Mitchell
2025-0577
· Alexander Frodsham
A patient's lifelong repeat prescription was removed by software without GP notification or patient choice, creating a risk that essential medication may …
|
North West
Cheshire
|
Optum | All Responded | 1/1 |
| 7 Nov 2025 |
Richard Worswick
2025-0564
· Alison Mutch
Unclear wound care instructions on hospital discharge and a lack of documented communication between the hospital and care home led to confusion. …
|
North West
Manchester South
|
Bamford Grange Care Home Stockport NHS Foundation Trust | All Responded | 2/2 |
| 7 Nov 2025 |
Ernest Gray
2025-0579
· Patricia Harding
The hospital failed to involve the patient's primary carer in discharge planning and neglected to provide holistic information about his fluctuating delirium, …
|
South East
Kent and Medway
|
East Kent Hospitals University NHS … | All Responded | 1/1 |
| 7 Nov 2025 |
Anthony Card
2026-0068
· Peter Taheri
There is no formal mechanism for police to share medium-risk mental health information with care providers, even with consent. This prevents crucial …
|
East of England
Suffolk
|
Suffolk Constabulary Suffolk County Council | All Responded | 2/2 |
| 6 Nov 2025 |
Aaron Taylor
2025-0566
· Christopher Long
Prison staff failed to open an ACCT process after a self-harm incident and lacked ACCT training. Keyworker sessions for vulnerable prisoners were …
|
North West
Lancashire and Blackburn with Darwen
|
[REDACTED] HMP Garth | All Responded | 1/1 |
| 6 Nov 2025 |
Aaron Taylor
2025-0565
· Christopher Long
HMP Garth has a critical lack of psychologist resources for prisoners, with severe staffing gaps and extensive waiting lists for mental health …
|
North West
Lancashire and Blackburn with Darwen
|
[REDACTED], Medical Director, Practice Plus … | All Responded | 1/1 |
| 6 Nov 2025 |
Samuel Vass
2025-0568
· Guy Davies
The lack of speed enforcement on a specific A3083 road stretch has contributed to multiple fatal collisions caused by excessive speeding.
|
South West
Cornwall & the Isles of Scilly
|
Service Director for Environment Cornwall … | No Identified Response | 0/1 |
| 6 Nov 2025 |
Judith Hughes
2025-0563
· Simon Milburn
The hospital's fall risk assessment tool is confusing due to unclear factor definitions, risking incorrect scores, insufficient observation levels, and increased patient …
|
East of England
Cambridgeshire and Peterborough
|
Chief Medical Officer for North … | All Responded | 1/1 |
| 5 Nov 2025 |
Vivian Nolan
2025-0560
· Paul Appleton
Clinicians lack sufficient knowledge and guidance on the increased risks associated with diagnostic colonoscopies for patients aged 80 and over.
|
North East
Teesside and Hartlepool
|
President of the British Society … | All Responded | 1/1 |
| 5 Nov 2025 |
Jennifer Cahill and Agnes Cahill
2025-0559
· Joanne Kearsley
There is a critical absence of national guidance for home births, particularly for high-risk pregnancies, leading to inconsistent midwife practice, insufficient risk …
|
North West
Manchester North
|
[REDACTED], Chief Executive of the … [REDACTED], Secretary of State for … | All Responded | 7/2 |
| 5 Nov 2025 |
Matthew Singh Prevention of future deaths report
2025-0567
· Kate Robertson
High availability and use of illicit psychoactive substances persist at HMP Berwyn, posing significant risks to prisoner health and contributing to future …
|
Wales
North Wales (East and Central)
|
Ministry of Justice c/o Government … Governor, HMP Berwyn | Partially Responded | 1/2 |
| 4 Nov 2025 |
Oliver Gorman
2025-0558
· Andrew Bridgman
There are inadequate age restrictions on dangerous aerosol products and unclear warnings about instant death. Social media platforms also fail to take …
|
North West
Manchester South
|
British Aerosol Manufacturers Association Department for Business and Trade Department for Culture, Media and … Department for Science, Innovation and … | All Responded | 4/4 |
| 4 Nov 2025 |
Maureen Christy
2025-0561
· Tim Holloway
There were critical shortcomings in disseminating and understanding policy changes, specifically for Covid contact testing, leading to clinician confusion and policies not …
|
North West
Blackpool & Fylde
|
Blackpool Teaching Hospitals NHS Foundation … | All Responded | 1/1 |
| 3 Nov 2025 |
Kathleen Ward
2025-0562
· Lorraine Harris
The emergency department faces persistent overcrowding with patients awaiting ward beds, leading to delays in appropriate emergency care and risking repeat incidents …
|
Yorkshire and the Humber
East Riding and Hull
|
Chief Executive – Hull Royal … | All Responded | 1/1 |
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
Joan Talbot
All Responded
Due to a lack of continuity across different admitting teams, the significance of a patient's repeated symptoms was not fully appreciated, delaying necessary investigation.
[REDACTED], Chief Executive Officer, …
Liliane Bowden
All Responded
Significant ambulance delays, caused by high demand and prolonged hospital handovers, led to extended waits for Category 3 calls. This poses a serious risk …
SCAS Legal Services
Tracey Oldfield
All Responded
Delayed prescription of usual medications for late-admitted patients leads to inappropriate alternative pain relief. The process for timely medication prescription for such patients is …
Royal Cornwall Hospital
Costas Chrysostomou
All Responded
There is potential for confusion due to differing interpretations of the term 'urgent' in cardiology pathways, and a lack of clarity among third-party providers …
NHS North Central London …
Jacqueline Aarons
All Responded
A lower hospital admission threshold for patients with learning disabilities is required. Furthermore, doctor's discharge instructions and safety netting advice for non-medical care staff …
Department of Health and …
Alan Mitchell
All Responded
A patient's lifelong repeat prescription was removed by software without GP notification or patient choice, creating a risk that essential medication may not be …
Optum
Richard Worswick
All Responded
Unclear wound care instructions on hospital discharge and a lack of documented communication between the hospital and care home led to confusion. The care …
Bamford Grange Care Home
Stockport NHS Foundation Trust
Ernest Gray
All Responded
The hospital failed to involve the patient's primary carer in discharge planning and neglected to provide holistic information about his fluctuating delirium, including potential …
East Kent Hospitals University …
Anthony Card
All Responded
There is no formal mechanism for police to share medium-risk mental health information with care providers, even with consent. This prevents crucial risk data …
Suffolk Constabulary
Suffolk County Council
Aaron Taylor
All Responded
Prison staff failed to open an ACCT process after a self-harm incident and lacked ACCT training. Keyworker sessions for vulnerable prisoners were not consistently …
[REDACTED] HMP Garth
Aaron Taylor
All Responded
HMP Garth has a critical lack of psychologist resources for prisoners, with severe staffing gaps and extensive waiting lists for mental health support.
[REDACTED], Medical Director, Practice …
Samuel Vass
No Identified Response
The lack of speed enforcement on a specific A3083 road stretch has contributed to multiple fatal collisions caused by excessive speeding.
Service Director for Environment …
Judith Hughes
All Responded
The hospital's fall risk assessment tool is confusing due to unclear factor definitions, risking incorrect scores, insufficient observation levels, and increased patient falls.
Chief Medical Officer for …
Vivian Nolan
All Responded
Clinicians lack sufficient knowledge and guidance on the increased risks associated with diagnostic colonoscopies for patients aged 80 and over.
President of the British …
Jennifer Cahill and Agnes Cahill
All Responded
There is a critical absence of national guidance for home births, particularly for high-risk pregnancies, leading to inconsistent midwife practice, insufficient risk discussions, and …
[REDACTED], Chief Executive of …
[REDACTED], Secretary of State …
Matthew Singh Prevention of future deaths report
Partially Responded
High availability and use of illicit psychoactive substances persist at HMP Berwyn, posing significant risks to prisoner health and contributing to future deaths.
Ministry of Justice c/o …
Governor, HMP Berwyn
Oliver Gorman
All Responded
There are inadequate age restrictions on dangerous aerosol products and unclear warnings about instant death. Social media platforms also fail to take responsibility for …
British Aerosol Manufacturers Association
Department for Business and …
Department for Culture, Media …
Maureen Christy
All Responded
There were critical shortcomings in disseminating and understanding policy changes, specifically for Covid contact testing, leading to clinician confusion and policies not being consistently …
Blackpool Teaching Hospitals NHS …
Kathleen Ward
All Responded
The emergency department faces persistent overcrowding with patients awaiting ward beds, leading to delays in appropriate emergency care and risking repeat incidents due to …
Chief Executive – Hull …