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 16 of 317
Showing 20 at a time
| Date | Report | Region / area | Addressee(s) | Status | Responses |
|---|---|---|---|---|---|
| 3 Nov 2025 |
Brian Lloyd
2025-0557
· Andrew Walker
Patients with two failed catheter insertion attempts are not being transferred to hospital promptly, creating a risk of delay in necessary medical …
|
London
North London
|
High Meadows Care Home | All Responded | 2/1 |
| 31 Oct 2025 |
Gloria Simon (1)
2025-0554
· David Lewis
A GP's misreading of oxygen saturation levels and incorrect assumption about the care facility's status led to inadequate assessment. The GP also …
|
North West
Liverpool and Wirral
|
Marine Lake Medical Practice | All Responded | 1/1 |
| 31 Oct 2025 |
Gloria Simon (2)
2025-0555
· David Lewis
Miscommunication about the care home's status led a GP to not visit. Care home staff lacked training on obtaining urgent clinical input …
|
North West
Liverpool and Wirral
|
Riversdale Care Home | All Responded | 1/1 |
| 31 Oct 2025 |
Gunaratnam Kannan
2025-0553
· Sarah Wood
There is a critical lack of joint policy and training among emergency and mental health services regarding Mental Capacity Act and Mental …
|
East Midlands
Nottingham and Nottinghamshire
|
East Midlands Ambulance Service Nottingham Healthcare NHS Foundation Trust Royal College of General Practitioners | All Responded | 3/3 |
| 29 Oct 2025 |
Evan Dandou-Dambelle
2025-0549
· Mary Hassell
Significant changes in a mental health patient's medication are not automatically factored into decisions about their required level of contact and observation.
|
London
Inner North London
|
East London NHS Foundation Trust | All Responded | 1/1 |
| 28 Oct 2025 |
Shannon Lee
2026-0032
· Zafar Siddique
There is persistent staff confusion regarding the exact timing of 15-minute observations, with no clear national standard, risking inconsistent patient monitoring.
|
West Midlands
Black Country
|
Black Country Healthcare NHS Foundation FBC Manby Bowdler Solicitors | Partially Responded | 1/2 |
| 28 Oct 2025 |
Alan Horrocks
2025-0545
· Peter Merchant
Patient observations were not completed per escalation guidance, delaying deterioration recognition. Increased ward capacity without corresponding nursing staff and existing staffing gaps …
|
Yorkshire and the Humber
West Yorkshire Western
|
Bradford Teaching Hospitals NHS Foundation … | All Responded | 1/1 |
| 28 Oct 2025 |
Patricia Genders
2025-0551
· Nick Armstrong
Over-reliance on A&E for mental health crises due to inadequate dedicated placements creates an unsuitable and insecure environment, risking patient deterioration and …
|
South East
West Sussex, Brighton and Hove
|
Department of Health and Social … NHS England & NHS Improvement | All Responded | 2/2 |
| 28 Oct 2025 |
Raymond Leake
2025-0546
· Lorraine Harris
An urgent radiology scan was missed, likely due to human error, and new preventative processes lack auditing due to staff shortages, leaving …
|
Yorkshire and the Humber
East Riding of Yorkshire and City …
|
Hull Royal Infirmary | All Responded | 1/1 |
| 28 Oct 2025 |
Lewis Garfield
2025-0547
· Hassan Shah
Ambulance service communications were inadequate, leading to delayed clinician review and escalation. Lengthy hospital handover delays severely impact ambulance availability and emergency …
|
East Midlands
Northamptonshire
|
Department of Health and Social … East Midlands Ambulance Service South Central Ambulance Service University Hospitals of Northamptonshire | All Responded | 4/4 |
| 27 Oct 2025 |
Danielle Jones
2025-0542
· Joanne Lees
The GP repeatedly prescribed large amounts of medication, including substances used in overdose, without adequate review, despite the patient self-reporting multiple overdoses …
|
West Midlands
The Black Country
|
Your Health Partnership Regis Medical … | All Responded | 1/1 |
| 27 Oct 2025 |
Louisa Walker (2)
2025-0544
· Heidi Connor
A significant majority of obstetricians have not received crucial specific training related to this incident, raising concerns about the trust's commitment to …
|
South East
Berkshire
|
Royal Berkshire Hospital | All Responded | 1/1 |
| 27 Oct 2025 |
Louisa Walker (1)
2025-0543
· Heidi Connor
There is a lack of national guidance and relevant training for the increasingly common obstetric emergency of impacted fetal head during caesarean …
|
South East
Berkshire
|
Royal College of Obstetricians and … | All Responded | 2/1 |
| 24 Oct 2025 |
Stephen Neville
2025-0556
· Sean Horstead
Nursing staff failed to properly conduct and record therapeutic observations due to misunderstanding and training deficits. The quality assurance and auditing processes …
|
East of England
Essex
|
Essex Partnership NHS Foundation Trust | All Responded | 1/1 |
| 24 Oct 2025 |
Caitlin Imber
2025-0538
· John Gittins
CAMHS closed a referral for a vulnerable child due to missing contact information without making further enquiries, causing a significant and potentially …
|
Wales
North Wales (East and Central)
|
BCUHB | All Responded | 1/1 |
| 24 Oct 2025 |
Sophie Towle
2025-0552
· Alexandra Poutney
There was a critical lack of joint policy and liaison between physical and mental health teams for complex cases involving foreign body …
|
East Midlands
Nottingham and Nottinghamshire
|
Department of Health and Social … Nottingham Healthcare NHS Foundation Trust Sherwood Forest Hospitals NHS Foundation … | Partially Responded | 2/3 |
| 24 Oct 2025 |
Alexander Lewis
2025-0539
· Aled Gruffydd
Pursuing drivers lacked the ability to communicate dynamic risk assessments, were overburdened with tasks leading to missed critical information, and police training …
|
Wales
Swansea Neath & Port Talbot
|
Home Office South Wales Police | All Responded | 3/2 |
| 23 Oct 2025 |
Rashida Sultana
2026-0026
· Zafar Siddique
Nursing staff lacked clarity on when to call the Emergency Medical Response Team for patients with a DNAR. There was also an …
|
West Midlands
Black Country
|
Leigh Day and Co Solicitors Sandwell and Birmingham Hospital NHS … | Partially Responded | 1/2 |
| 23 Oct 2025 |
Lynn Silcock
2025-0636
· Heath Westerman
A patient was discharged by gastroenterology without cardiology consultation or follow-up, due to a lack of communication and document exchange between teams, …
|
West Midlands
Shropshire, Telford & Wrekin
|
NHS England Shrewsbury and Telford NHS Hospital … | All Responded | 2/2 |
| 23 Oct 2025 |
Ann Campbell
2025-0535
· Andrew Cox
The steps are unsafe as the handrail is too low and short, preventing individuals from adequately steadying themselves when descending.
|
South West
Cornwall and the Isles of Scilly
|
Landlord | All Responded | 1/1 |
Brian Lloyd
All Responded
Patients with two failed catheter insertion attempts are not being transferred to hospital promptly, creating a risk of delay in necessary medical intervention.
High Meadows Care Home
Gloria Simon (1)
All Responded
A GP's misreading of oxygen saturation levels and incorrect assumption about the care facility's status led to inadequate assessment. The GP also failed to …
Marine Lake Medical Practice
Gloria Simon (2)
All Responded
Miscommunication about the care home's status led a GP to not visit. Care home staff lacked training on obtaining urgent clinical input when a …
Riversdale Care Home
Gunaratnam Kannan
All Responded
There is a critical lack of joint policy and training among emergency and mental health services regarding Mental Capacity Act and Mental Health Act …
East Midlands Ambulance Service
Nottingham Healthcare NHS Foundation …
Royal College of General …
Evan Dandou-Dambelle
All Responded
Significant changes in a mental health patient's medication are not automatically factored into decisions about their required level of contact and observation.
East London NHS Foundation …
Shannon Lee
Partially Responded
There is persistent staff confusion regarding the exact timing of 15-minute observations, with no clear national standard, risking inconsistent patient monitoring.
Black Country Healthcare NHS …
FBC Manby Bowdler Solicitors
Alan Horrocks
All Responded
Patient observations were not completed per escalation guidance, delaying deterioration recognition. Increased ward capacity without corresponding nursing staff and existing staffing gaps compromised patient …
Bradford Teaching Hospitals NHS …
Patricia Genders
All Responded
Over-reliance on A&E for mental health crises due to inadequate dedicated placements creates an unsuitable and insecure environment, risking patient deterioration and abscondment.
Department of Health and …
NHS England & NHS …
Raymond Leake
All Responded
An urgent radiology scan was missed, likely due to human error, and new preventative processes lack auditing due to staff shortages, leaving their effectiveness …
Hull Royal Infirmary
Lewis Garfield
All Responded
Ambulance service communications were inadequate, leading to delayed clinician review and escalation. Lengthy hospital handover delays severely impact ambulance availability and emergency department flow.
Department of Health and …
East Midlands Ambulance Service
South Central Ambulance Service
Danielle Jones
All Responded
The GP repeatedly prescribed large amounts of medication, including substances used in overdose, without adequate review, despite the patient self-reporting multiple overdoses and external …
Your Health Partnership Regis …
Louisa Walker (2)
All Responded
A significant majority of obstetricians have not received crucial specific training related to this incident, raising concerns about the trust's commitment to learning and …
Royal Berkshire Hospital
Louisa Walker (1)
All Responded
There is a lack of national guidance and relevant training for the increasingly common obstetric emergency of impacted fetal head during caesarean sections.
Royal College of Obstetricians …
Stephen Neville
All Responded
Nursing staff failed to properly conduct and record therapeutic observations due to misunderstanding and training deficits. The quality assurance and auditing processes for these …
Essex Partnership NHS Foundation …
Caitlin Imber
All Responded
CAMHS closed a referral for a vulnerable child due to missing contact information without making further enquiries, causing a significant and potentially dangerous delay …
BCUHB
Sophie Towle
Partially Responded
There was a critical lack of joint policy and liaison between physical and mental health teams for complex cases involving foreign body insertion, and …
Department of Health and …
Nottingham Healthcare NHS Foundation …
Sherwood Forest Hospitals NHS …
Alexander Lewis
All Responded
Pursuing drivers lacked the ability to communicate dynamic risk assessments, were overburdened with tasks leading to missed critical information, and police training suggested a …
Home Office
South Wales Police
Rashida Sultana
Partially Responded
Nursing staff lacked clarity on when to call the Emergency Medical Response Team for patients with a DNAR. There was also an absence of …
Leigh Day and Co …
Sandwell and Birmingham Hospital …
Lynn Silcock
All Responded
A patient was discharged by gastroenterology without cardiology consultation or follow-up, due to a lack of communication and document exchange between teams, leading them …
NHS England
Shrewsbury and Telford NHS …
Ann Campbell
All Responded
The steps are unsafe as the handrail is too low and short, preventing individuals from adequately steadying themselves when descending.
Landlord