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 17 of 317
Showing 20 at a time
| Date | Report | Region / area | Addressee(s) | Status | Responses |
|---|---|---|---|---|---|
| 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 |
| 23 Oct 2025 |
Mark Foster
2025-0537
· Kirsty Gomersal
The practice suffers from a lack of unified leadership, poor governance, and an inadequate system for investigating incidents.
|
North West
Cumbria
|
Castlegate & Derwent Surgery | All Responded | 1/1 |
| 22 Oct 2025 |
Amy Cross
2025-0531
· Peter Harrowing
There is no system to ensure vital healthcare information, including medication and observations, is shared between criminal justice healthcare providers, and no …
|
South West
Avon
|
IPRS Aeromed Mitie NHS England Practice Plus Group | Partially Responded | 1/4 |
| 22 Oct 2025 |
Ricky Monahan
2025-0533
· Louise Hunt
An unprotected fire escape allowed easy roof access from a rehabilitation unit due to inadequate railings, without an environmental risk assessment. There …
|
West Midlands
Birmingham and Solihull
|
Birmingham and Solihull Integrated Care … Care Quality Commission NHS England | All Responded | 3/3 |
| 21 Oct 2025 |
Steven Davidson
2025-0536
· Stephen Simblet
Healthcare staff at HMP Chelmsford lack proficiency in navigating System One records to find critical past self-harm information, or are unaware of …
|
East of England
Essex
|
HCRG Care Group | All Responded | 1/1 |
| 21 Oct 2025 |
Paul Appleby
2025-0530
· Anne Pember
The absence of a regular Saturday Court Service by the Liaison and Diversion Team, relying solely on an 'On Call' system, raises …
|
East Midlands
Northamptonshire
|
Northamptonshire Healthcare Foundation Trust | All Responded | 1/1 |
| 21 Oct 2025 |
Amber Walker
2025-0528
· Brendan Allen
Doctors are reluctant or presume others have discussed SUDEP with epilepsy patients, despite its critical importance. There's a lack of universal use …
|
South West
Dorset
|
Department of Health and Social … | All Responded | 1/1 |
| 20 Oct 2025 |
Declan Carr
2025-0541
· Sarah Middleton
Inadequate national policy for sharing information on psycho-social support for substance misuse during prisoner transfers risks continuity of care and future deaths.
|
Yorkshire and the Humber
East Riding of Yorkshire and City …
|
NHS England | All Responded | 1/1 |
| 20 Oct 2025 |
Stuart Fowkes
2025-0527
· Joanne Lees
Devon and Cornwall Police failed to share vital information regarding the deceased's suicidal intent with West Midlands Police, leading to critical risk …
|
West Midlands
The Black Country
|
Devon & Cornwall Police | All Responded | 1/1 |
| 20 Oct 2025 |
Scott Berry
2026-0038
· Sarah Middleton
Imprisonment for Public Protection (IPP) prisoners face profound hopelessness and mental health suffering due to indefinite detention and lack of access to …
|
Yorkshire and the Humber
City of Kingston Upon Hull and …
|
HM Prison & Probation Service Minister of State for Prisons, … | All Responded | 1/2 |
| 20 Oct 2025 |
Marc Davies
2025-0525
· Caroline Saunders
Inadequate welfare checks by security guards, stemming from a lack of training on proper procedures and documentation, risked residents not receiving timely …
|
Wales
Gwent
|
MJ Events Monmouthshire County Council | Partially Responded | 1/2 |
| 20 Oct 2025 |
John Rust
2025-0524
· Adam Hodson
Mandatory training for automated CSF drainage systems is not adequately enforced, with many staff untrained. There's no sustainable plan to ensure all …
|
West Midlands
Birmingham and Solihull
|
University Hospitals Birmingham NHS Foundation … | All Responded | 1/1 |
| 19 Oct 2025 |
Alexander McCormack
2025-0548
· Sophie Lomas
Inefficient transfer of missing persons cases between police forces due to inadequate training for transferees on data import procedures, risking delays in …
|
East Midlands
Northamptonshire
|
Northamptonshire Police | All Responded | 1/1 |
| 17 Oct 2025 |
Melanie Walker
2025-0529
· Timothy Brennand
Heart monitors have a critical design flaw where disconnected leads do not continuously re-alarm after initial acknowledgement, risking unobserved and fatal cardiac …
|
North West
Manchester West
|
Department of Health and Social … Philips Electronics UK Ltd NHS England | All Responded | 3/3 |
| 17 Oct 2025 |
Owen Donnelly
2025-0532
· Timothy Brennand
Easy online access to information for constructing weapons, currently not illegal to possess, creates a real risk due to the proliferation of …
|
North West
Manchester West
|
Department of Health and Social … Home Department | Partially Responded | 1/2 |
| 16 Oct 2025 |
Theo Treharne-Jones
2025-0521
· Gavin Knox
The hotel room lacked secondary security for its easily disengaged door locks, and the pool had no physical barrier, allowing unsupervised access …
|
Wales
South Wales Central
|
Association of British Travel Agents TUI UK | All Responded | 2/2 |
| 16 Oct 2025 |
Martin Evans, Patricia Evans and Neil Errington
2025-0523
· Robert Cohen
The DVLA's over-reliance on drivers self-reporting medical unfitness is problematic, as some individuals with impairments may lack insight or be unwilling to …
|
North West
Cumbria
|
Department for Transport | All Responded | 2/1 |
| 15 Oct 2025 |
Tony Duncan
2025-0516
· Alison Hewitt
A psychiatric liaison team failed to conduct a proper risk assessment, overlooking suicidal ideation and acute mental health deterioration, leading to inappropriate …
|
London
City of London
|
South London and Maudsley NHS … | All Responded | 1/1 |
| 15 Oct 2025 |
Malik Bunton
2025-0519
· Catherine Cundy
Inadequate inquiry into a previous incident, flawed clinical review processes, and deliberate obstructions to evidence gathering impeded the RAF's ability to assess …
|
Yorkshire and the Humber
North Yorkshire and York
|
Ministry of Defence | All Responded | 1/1 |
| 15 Oct 2025 |
Katie Overd
2025-0517
· Joanne Kearsley
A lack of proactive public communication about the "Right Care Right Person" policy risks the public delaying seeking emergency assistance, misunderstanding response …
|
North West
Manchester North
|
College of Policing RCRP Strategic Partnership Board | All Responded | 3/2 |
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
Mark Foster
All Responded
The practice suffers from a lack of unified leadership, poor governance, and an inadequate system for investigating incidents.
Castlegate & Derwent Surgery
Amy Cross
Partially Responded
There is no system to ensure vital healthcare information, including medication and observations, is shared between criminal justice healthcare providers, and no standard, accessible …
IPRS Aeromed
Mitie
NHS England
Ricky Monahan
All Responded
An unprotected fire escape allowed easy roof access from a rehabilitation unit due to inadequate railings, without an environmental risk assessment. There are no …
Birmingham and Solihull Integrated …
Care Quality Commission
NHS England
Steven Davidson
All Responded
Healthcare staff at HMP Chelmsford lack proficiency in navigating System One records to find critical past self-harm information, or are unaware of its importance …
HCRG Care Group
Paul Appleby
All Responded
The absence of a regular Saturday Court Service by the Liaison and Diversion Team, relying solely on an 'On Call' system, raises concerns about …
Northamptonshire Healthcare Foundation Trust
Amber Walker
All Responded
Doctors are reluctant or presume others have discussed SUDEP with epilepsy patients, despite its critical importance. There's a lack of universal use of SUDEP …
Department of Health and …
Declan Carr
All Responded
Inadequate national policy for sharing information on psycho-social support for substance misuse during prisoner transfers risks continuity of care and future deaths.
NHS England
Stuart Fowkes
All Responded
Devon and Cornwall Police failed to share vital information regarding the deceased's suicidal intent with West Midlands Police, leading to critical risk information being …
Devon & Cornwall Police
Scott Berry
All Responded
Imprisonment for Public Protection (IPP) prisoners face profound hopelessness and mental health suffering due to indefinite detention and lack of access to parole reviews …
HM Prison & Probation …
Minister of State for …
Marc Davies
Partially Responded
Inadequate welfare checks by security guards, stemming from a lack of training on proper procedures and documentation, risked residents not receiving timely medical care.
MJ Events
Monmouthshire County Council
John Rust
All Responded
Mandatory training for automated CSF drainage systems is not adequately enforced, with many staff untrained. There's no sustainable plan to ensure all current and …
University Hospitals Birmingham NHS …
Alexander McCormack
All Responded
Inefficient transfer of missing persons cases between police forces due to inadequate training for transferees on data import procedures, risking delays in risk assessment …
Northamptonshire Police
Melanie Walker
All Responded
Heart monitors have a critical design flaw where disconnected leads do not continuously re-alarm after initial acknowledgement, risking unobserved and fatal cardiac events in …
Department of Health and …
Philips Electronics UK Ltd
NHS England
Owen Donnelly
Partially Responded
Easy online access to information for constructing weapons, currently not illegal to possess, creates a real risk due to the proliferation of unlicensed weapons …
Department of Health and …
Home Department
Theo Treharne-Jones
All Responded
The hotel room lacked secondary security for its easily disengaged door locks, and the pool had no physical barrier, allowing unsupervised access by a …
Association of British Travel …
TUI UK
Martin Evans, Patricia Evans and Neil Errington
All Responded
The DVLA's over-reliance on drivers self-reporting medical unfitness is problematic, as some individuals with impairments may lack insight or be unwilling to inform them, …
Department for Transport
Tony Duncan
All Responded
A psychiatric liaison team failed to conduct a proper risk assessment, overlooking suicidal ideation and acute mental health deterioration, leading to inappropriate discharge without …
South London and Maudsley …
Malik Bunton
All Responded
Inadequate inquiry into a previous incident, flawed clinical review processes, and deliberate obstructions to evidence gathering impeded the RAF's ability to assess suicide risk …
Ministry of Defence
Katie Overd
All Responded
A lack of proactive public communication about the "Right Care Right Person" policy risks the public delaying seeking emergency assistance, misunderstanding response times.
College of Policing
RCRP Strategic Partnership Board