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 18 of 317
Showing 20 at a time
| Date | Report | Region / area | Addressee(s) | Status | Responses |
|---|---|---|---|---|---|
| 14 Oct 2025 |
Paula Doreen
2025-0511
· Liliane Field
National risk of concurrent paracetamol prescriptions due to prescribing system deficiencies and inadequate assessment of patient confusion. Inconsistent management of therapeutic excess …
|
London
Inner South London
|
Royal Pharmaceutical Society (RPS) Lewisham and Greenwich NHS Trust Medicine and Healthcare Product Regulatory … NHS England | All Responded | 5/6 |
| 14 Oct 2025 |
William Roath
2025-0518
· David Reid
A doctor's failure to advise "Nil by Mouth" and delay a SALT referral led to continued oral feeding, worsening aspiration pneumonia. Specific …
|
West Midlands
Worcestershire
|
University Hospitals Birmingham NHS Foundation … | All Responded | 1/1 |
| 14 Oct 2025 |
Mohan Hothi
2025-0513
· Graeme Irvine
The Trust failed to investigate two serious unwitnessed falls, hindering its ability to identify and remediate suboptimal practices, with vague evidence of …
|
London
East London
|
Barking, Havering and Redbridge University … | No Identified Response | 0/1 |
| 14 Oct 2025 |
David Jones
2025-0514
· Nathanael Hartley
The Emergency Department failed to review an undiagnosed aortic dissection, and a middle-grade doctor did not escalate a changing clinical picture, indicating …
|
East Midlands
Nottingham and Nottinghamshire
|
Nottingham University Hospitals NHS Trust | All Responded | 1/1 |
| 14 Oct 2025 |
Thompson Elliott
2025-0515
· David Place
Absence of clear policy for medication administration when hospital discharge letters are missing caused staff confusion, resulting in an opioid overdose and …
|
North East
Sunderland
|
Care UK | All Responded | 1/1 |
| 13 Oct 2025 |
Abigail Jelley
2025-0509
· Nicholas Walker
Community Mental Health Teams lack mandatory perinatal red flag training and professional curiosity, exacerbated by cultural issues and structural leadership problems, risking …
|
South East
Hampshire, Portsmouth and Southampton
|
Hampshire and Isle of Wight … | All Responded | 1/1 |
| 13 Oct 2025 |
Jack Peatling
2025-0510
· Sean Horstead
A chronic lack of available in-patient mental health beds for high-risk patients who cannot be safely managed in the community led to …
|
East of England
Essex
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 13 Oct 2025 |
Mark Townsend
2025-0512
· Tanyka Rawden
Stewards' lack of awareness regarding the nearest radio location caused delays in summoning medical assistance, posing a future risk for timely emergency …
|
Yorkshire and the Humber
South Yorkshire West
|
Sheffield Wednesday Football Club | All Responded | 1/1 |
| 13 Oct 2025 |
Jamie Funnell
2025-0508
· Rachel Redman
An expired alcohol dependence policy, chaotic emergency care with faulty equipment and incorrect CPR, and insufficient training evidence demonstrate a cavalier attitude …
|
South East
East Sussex
|
Practice Plus Group | All Responded | 1/1 |
| 11 Oct 2025 |
Joanna Chamberlain
2025-0571
· Joseph Turner
A gap exists in safe spaces for mental health patients needing more support than home teams provide. National guidance is needed for …
|
South East
West Sussex, Brighton and Hove
|
NHS England | All Responded | 1/1 |
| 11 Oct 2025 |
Sarah Healey
2025-0520
· Joseph Turner
Inadequate information sharing and a lack of a joined-up approach across health services for mental health patients with physical issues led to …
|
South East
West Sussex, Brighton and Hove
|
Department of Health and Social … | All Responded | 1/1 |
| 10 Oct 2025 |
Jillian Steedman
2025-0506
· Sonia Hayes
Failures in information sharing, incomplete care plans, and inadequate risk assessments led to an inappropriate discharge placement that was not adequately monitored, …
|
East of England
Essex
|
Essex County Council Essex Partnership NHS Foundation Trust | All Responded | 2/2 |
| 10 Oct 2025 |
William Puplett
2025-0526
· Andrew Walker
Emergency dispatch protocols lack specific questions for tracheostomy patients regarding suction equipment availability and use, risking delayed high-priority responses for breathing difficulties.
|
London
North London
|
International Academies of Emergency Dispatch | All Responded | 1/1 |
| 10 Oct 2025 |
Adrienne Studholme
2025-0504
· Christopher Long
Inaccurate fluid balance charting, unrecorded seizure activity, and a lack of procedures for ED readmission after recent surgery, including insufficient triage training, …
|
North West
Lancashire and Blackburn with Darwen
|
East Lancashire NHS Trust | All Responded | 1/1 |
| 9 Oct 2025 |
Pauline Stirling
2025-0503
· Leila Benyounes
Inadequate documentation of positional changes, insufficient training for agency nurses, and a lack of wound care training despite safeguarding referrals contributed to …
|
North East
Gateshead and South Tyneside
|
Malhorta Group Prestwick Care | Partially Responded | 1/2 |
| 9 Oct 2025 |
Stella LeClaire
2025-0619
· Christopher Williams
The rising number of deaths from a substance sold for suicide raises concerns, emphasizing the need for routine toxicological analysis to improve …
|
East Midlands
Northamptonshire
|
Secretary of State for Health … Secretary of State for the … | All Responded | 1/2 |
| 9 Oct 2025 |
Leo Barber
2025-0505
· Edmund Gritt
Vulnerable children can access online suicide material, and international service providers’ jurisdictional stance can obstruct coronial investigations, hindering efforts to prevent future …
|
London
South London
|
Google UK & Ireland | All Responded | 1/1 |
| 9 Oct 2025 |
Derek Crowther
2025-0500
· Chris Morris
Staff worked without mandatory life support training, and the lack of a digital system for contemporaneous patient observations hindered accurate monitoring and …
|
North West
Manchester South
|
Pennine Care NHS Foundation Trust | All Responded | 1/1 |
| 9 Oct 2025 |
Matthew Goldsmith
2025-0499
· Nadia Persaud
Multiple significant abnormal findings in abdominal CT scans were repeatedly missed by radiologists, aggravated by the absence of a required peer review …
|
London
East London
|
Barking, Havering and Redbridge University … | All Responded | 1/1 |
| 8 Oct 2025 |
William King
2025-0496
· Sean Cummings
Failures in documenting consent, insufficient explanation of treatment risks, and a lack of clear professional responsibility meant essential medical policies were not …
|
South East
Milton Keynes
|
Association of Anaesthetists Milton Keynes University Hospital Royal College of Anaesthetists Royal College of Surgeons | All Responded | 3/4 |
Paula Doreen
All Responded
National risk of concurrent paracetamol prescriptions due to prescribing system deficiencies and inadequate assessment of patient confusion. Inconsistent management of therapeutic excess persists, and …
Royal Pharmaceutical Society (RPS)
Lewisham and Greenwich NHS …
Medicine and Healthcare Product …
William Roath
All Responded
A doctor's failure to advise "Nil by Mouth" and delay a SALT referral led to continued oral feeding, worsening aspiration pneumonia. Specific actions for …
University Hospitals Birmingham NHS …
Mohan Hothi
No Identified Response
The Trust failed to investigate two serious unwitnessed falls, hindering its ability to identify and remediate suboptimal practices, with vague evidence of reflection and …
Barking, Havering and Redbridge …
David Jones
All Responded
The Emergency Department failed to review an undiagnosed aortic dissection, and a middle-grade doctor did not escalate a changing clinical picture, indicating ineffective training …
Nottingham University Hospitals NHS …
Thompson Elliott
All Responded
Absence of clear policy for medication administration when hospital discharge letters are missing caused staff confusion, resulting in an opioid overdose and continued use …
Care UK
Abigail Jelley
All Responded
Community Mental Health Teams lack mandatory perinatal red flag training and professional curiosity, exacerbated by cultural issues and structural leadership problems, risking inappropriate care …
Hampshire and Isle of …
Jack Peatling
All Responded
A chronic lack of available in-patient mental health beds for high-risk patients who cannot be safely managed in the community led to an avoidable …
Department of Health and …
NHS England
Mark Townsend
All Responded
Stewards' lack of awareness regarding the nearest radio location caused delays in summoning medical assistance, posing a future risk for timely emergency response.
Sheffield Wednesday Football Club
Jamie Funnell
All Responded
An expired alcohol dependence policy, chaotic emergency care with faulty equipment and incorrect CPR, and insufficient training evidence demonstrate a cavalier attitude to patient …
Practice Plus Group
Joanna Chamberlain
All Responded
A gap exists in safe spaces for mental health patients needing more support than home teams provide. National guidance is needed for proactively including …
NHS England
Sarah Healey
All Responded
Inadequate information sharing and a lack of a joined-up approach across health services for mental health patients with physical issues led to fragmented care. …
Department of Health and …
Jillian Steedman
All Responded
Failures in information sharing, incomplete care plans, and inadequate risk assessments led to an inappropriate discharge placement that was not adequately monitored, despite repeated …
Essex County Council
Essex Partnership NHS Foundation …
William Puplett
All Responded
Emergency dispatch protocols lack specific questions for tracheostomy patients regarding suction equipment availability and use, risking delayed high-priority responses for breathing difficulties.
International Academies of Emergency …
Adrienne Studholme
All Responded
Inaccurate fluid balance charting, unrecorded seizure activity, and a lack of procedures for ED readmission after recent surgery, including insufficient triage training, posed significant …
East Lancashire NHS Trust
Pauline Stirling
Partially Responded
Inadequate documentation of positional changes, insufficient training for agency nurses, and a lack of wound care training despite safeguarding referrals contributed to poor patient …
Malhorta Group
Prestwick Care
Stella LeClaire
All Responded
The rising number of deaths from a substance sold for suicide raises concerns, emphasizing the need for routine toxicological analysis to improve evidence for …
Secretary of State for …
Secretary of State for …
Leo Barber
All Responded
Vulnerable children can access online suicide material, and international service providers’ jurisdictional stance can obstruct coronial investigations, hindering efforts to prevent future deaths.
Google UK & Ireland
Derek Crowther
All Responded
Staff worked without mandatory life support training, and the lack of a digital system for contemporaneous patient observations hindered accurate monitoring and trend analysis, …
Pennine Care NHS Foundation …
Matthew Goldsmith
All Responded
Multiple significant abnormal findings in abdominal CT scans were repeatedly missed by radiologists, aggravated by the absence of a required peer review system for …
Barking, Havering and Redbridge …
William King
All Responded
Failures in documenting consent, insufficient explanation of treatment risks, and a lack of clear professional responsibility meant essential medical policies were not followed, creating …
Association of Anaesthetists
Milton Keynes University Hospital
Royal College of Anaesthetists