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 19 of 317
Showing 20 at a time
| Date | Report | Region / area | Addressee(s) | Status | Responses |
|---|---|---|---|---|---|
| 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 |
| 8 Oct 2025 |
Richard Hunt
2025-0498
· Fiona Butler
Deliberate tampering with prison fire alarm systems, disabling their buzzers, led to undetected fires, a systemic issue worsened by the absence of …
|
East Midlands
Rutland and North Leicestershire
|
His Majesty’s Prison & Probation … Crown Premises Fire & Safety … Governor HMP Stocken | Partially Responded | 1/3 |
| 7 Oct 2025 |
Angela Thompson
2026-0027
· Paul Marks
A lack of liaison between prison and community psychiatric services for released prisoners with ongoing mental health issues, especially when geographically distant, …
|
Yorkshire and the Humber
City of Kingston Upon Hull and …
|
HM Prison & Probation Service | All Responded | 2/1 |
| 7 Oct 2025 |
Imogen Nunn Prevention of future deaths report
2025-0494
· Penelope Schofield
A national shortage and lack of regulation for British Sign Language interpreters, alongside procurement issues and few BSL-proficient clinicians, create significant risks …
|
South East
West Sussex, Brighton and Hove
|
Cabinet Office, 1 Horse Guards … Minister of State for Education, … Minister of State, Minister for … Secretary of State for Health … | Partially Responded | 1/4 |
| 7 Oct 2025 |
Ann Laskowsky
2025-0502
· Charlotte Keighley
Inadequate first aid training for police officers in assessing patient conditions and poor awareness of a dedicated medical advice line led to …
|
Yorkshire and the Humber
West Yorkshire Western
|
National College of Policing National Police Chiefs Council | All Responded | 3/2 |
| 7 Oct 2025 |
Amanda Wood
2025-0495
· Chris Morris
No sepsis screen was performed before discharge from the Emergency Department, indicating a failure in early identification and treatment of sepsis.
|
North West
Manchester South
|
Chief Executive, Tameside and Glossop … | All Responded | 1/1 |
| 6 Oct 2025 |
Steven Turzynski
2025-0492
· Caroline Saunders
Inadequate communication between dietetic teams and insufficient monitoring of telephone-based nutritional assessments for cancer patients led to poor nutritional status and potentially …
|
Wales
Gwent
|
Aneurin Bevan University Health Board Velindre University Nhs Trust | All Responded | 2/2 |
| 2 Oct 2025 |
Beatrice Smith
2025-0493
· Robert Cohen
No effective internal investigation was conducted after the death, missing learning opportunities. Staff also received no additional training or guidance, risking a …
|
North West
Cumbria
|
Chief Executive Officer, Harbour Healthcare … | All Responded | 1/1 |
| 2 Oct 2025 |
Georgia Barter
2025-0491
· Dr Shirley Radcliffe
Frontline police officers face difficulty accessing the Police National Database for domestic abuse history across different force areas, hindering proactive identification and …
|
London
East London
|
[REDACTED] Secretary of State for … | All Responded | 1/1 |
| 1 Oct 2025 |
Milos Jankovic
2025-0490
· Rachel Knight
Inadequate follow-up for Barrett’s oesophagus in primary care, including a lack of routine recall and prompts for GPs to consider endoscopy, is …
|
London
East London
|
Digital Health & Care Wales [REDACTED] Chief Executive of Digital … Minister for Health and Social … | All Responded | 1/3 |
| 29 Sep 2025 |
Susan Barrett
2025-0590
· Sean Horstead
Serious concerns exist regarding the absence of embedded Tissue Viability Nurses and a Tissue Viability Service in community hospitals, leading to inadequate …
|
East of England
Essex
|
East Suffolk and North Essex … | All Responded | 1/1 |
| 29 Sep 2025 |
Naomi Aylott
2025-0522
· Robert Simpson
The patient received no face-to-face care due to geographical distance, and the CMHT had inadequate risk assessment training, auditing, and family involvement …
|
South East
Hampshire, Portsmouth and Southampton
|
Hampshire and Isle of Wight … | All Responded | 1/1 |
| 29 Sep 2025 |
Mohammad Asghar
2025-0489
· Graeme Irvine
The Trust's governance failed to investigate a serious incident, despite multiple triggers and court orders, revealing a misunderstanding of patient safety guidelines …
|
London
East London
|
[REDACTED] , Chief Executive Officer, … | All Responded | 1/1 |
| 29 Sep 2025 |
Jake Girton
2025-0488
· Graeme Irvine
Police failed to inform the hospital of a patient's release from custody, hindering mental health support efforts. The Metropolitan Police Service also …
|
London
East London
|
[REDACTED], The Commissioner of Police … | All Responded | 1/1 |
| 26 Sep 2025 |
Richard Ellis
2025-0483
· Joanne Andrews
There are no legal requirements for the servicing and maintenance of agricultural tractors, leaving safety dependent solely on owner discretion and posing …
|
South East
West Sussex, Brighton and Hove
|
Department for Transport, Great Minster … | All Responded | 1/1 |
| 25 Sep 2025 |
Catherine Moore
2025-0486
· Daniel Sharpstone
The MOD's vehicle maintenance system (JAMES) is complex, lacks audit capabilities, and has no formal processes for inspecting, testing, or providing feedback …
|
East of England
Suffolk
|
Secretary of State for Defence | No Identified Response | 0/1 |
| 25 Sep 2025 |
Pamela Honeybone
2025-0485
· Catherine Cundy
Persistent failures in patient identification processes, including staff not checking identity and delayed recognition of errors, continue to pose a significant risk …
|
Yorkshire and the Humber
North Yorkshire and York
|
York and Scarborough Teaching Hospitals … | All Responded | 1/1 |
| 25 Sep 2025 |
Zara Cheesman
2025-0481
· Elizabeth Didcock
Emergency medical services lacked detailed understanding of child assessment issues, relied on incorrect physiological scoring, and had insufficient audit, monitoring, and professional …
|
East Midlands
Nottingham and Nottinghamshire
|
Chief Executive, East Midlands Ambulance … | All Responded | 1/1 |
| 24 Sep 2025 |
Steven Hart
2025-0487
· Sean Cummings
Systemic failings included an unmonitored ligature point in a 'safer cell,' inadequate communication of mental state risks during handovers, and observations not …
|
East of England
Bedfordshire and Luton
|
Governor [REDACTED], HM Chief Inspector … | All Responded | 1/1 |
| 24 Sep 2025 |
Mark Smith
2025-0478
· Sean Horstead
The GP practice lacked a system or policy to ensure appropriate medication reviews for vulnerable patients with addiction or self-harm history, risking …
|
East of England
Essex
|
Addison House Surgery | All Responded | 1/1 |
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
Richard Hunt
Partially Responded
Deliberate tampering with prison fire alarm systems, disabling their buzzers, led to undetected fires, a systemic issue worsened by the absence of central oversight …
His Majesty’s Prison & …
Crown Premises Fire & …
Governor HMP Stocken
Angela Thompson
All Responded
A lack of liaison between prison and community psychiatric services for released prisoners with ongoing mental health issues, especially when geographically distant, creates risks …
HM Prison & Probation …
Imogen Nunn Prevention of future deaths report
Partially Responded
A national shortage and lack of regulation for British Sign Language interpreters, alongside procurement issues and few BSL-proficient clinicians, create significant risks for deaf …
Cabinet Office, 1 Horse …
Minister of State for …
Minister of State, Minister …
Ann Laskowsky
All Responded
Inadequate first aid training for police officers in assessing patient conditions and poor awareness of a dedicated medical advice line led to a failure …
National College of Policing
National Police Chiefs Council
Amanda Wood
All Responded
No sepsis screen was performed before discharge from the Emergency Department, indicating a failure in early identification and treatment of sepsis.
Chief Executive, Tameside and …
Steven Turzynski
All Responded
Inadequate communication between dietetic teams and insufficient monitoring of telephone-based nutritional assessments for cancer patients led to poor nutritional status and potentially earlier death.
Aneurin Bevan University Health …
Velindre University Nhs Trust
Beatrice Smith
All Responded
No effective internal investigation was conducted after the death, missing learning opportunities. Staff also received no additional training or guidance, risking a repeat of …
Chief Executive Officer, Harbour …
Georgia Barter
All Responded
Frontline police officers face difficulty accessing the Police National Database for domestic abuse history across different force areas, hindering proactive identification and intervention for …
[REDACTED] Secretary of State …
Milos Jankovic
All Responded
Inadequate follow-up for Barrett’s oesophagus in primary care, including a lack of routine recall and prompts for GPs to consider endoscopy, is leading to …
Digital Health & Care …
[REDACTED] Chief Executive of …
Minister for Health and …
Susan Barrett
All Responded
Serious concerns exist regarding the absence of embedded Tissue Viability Nurses and a Tissue Viability Service in community hospitals, leading to inadequate care for …
East Suffolk and North …
Naomi Aylott
All Responded
The patient received no face-to-face care due to geographical distance, and the CMHT had inadequate risk assessment training, auditing, and family involvement in remote …
Hampshire and Isle of …
Mohammad Asghar
All Responded
The Trust's governance failed to investigate a serious incident, despite multiple triggers and court orders, revealing a misunderstanding of patient safety guidelines and an …
[REDACTED] , Chief Executive …
Jake Girton
All Responded
Police failed to inform the hospital of a patient's release from custody, hindering mental health support efforts. The Metropolitan Police Service also showed no …
[REDACTED], The Commissioner of …
Richard Ellis
All Responded
There are no legal requirements for the servicing and maintenance of agricultural tractors, leaving safety dependent solely on owner discretion and posing a risk …
Department for Transport, Great …
Catherine Moore
No Identified Response
The MOD's vehicle maintenance system (JAMES) is complex, lacks audit capabilities, and has no formal processes for inspecting, testing, or providing feedback on repairs, …
Secretary of State for …
Pamela Honeybone
All Responded
Persistent failures in patient identification processes, including staff not checking identity and delayed recognition of errors, continue to pose a significant risk to patient …
York and Scarborough Teaching …
Zara Cheesman
All Responded
Emergency medical services lacked detailed understanding of child assessment issues, relied on incorrect physiological scoring, and had insufficient audit, monitoring, and professional development for …
Chief Executive, East Midlands …
Steven Hart
All Responded
Systemic failings included an unmonitored ligature point in a 'safer cell,' inadequate communication of mental state risks during handovers, and observations not being carried …
Governor [REDACTED], HM Chief …
Mark Smith
All Responded
The GP practice lacked a system or policy to ensure appropriate medication reviews for vulnerable patients with addiction or self-harm history, risking stockpiling and …
Addison House Surgery