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 2 of 317
Showing 20 at a time
| Date | Report | Region / area | Addressee(s) | Status | Responses |
|---|---|---|---|---|---|
| 7 Apr 2026 |
Joshua Perry
2026-0206
· Helen Rimmer
A conflict exists between Building Regulations and BSI Standards regarding the measurement of barrier heights when a wall or parapet is used …
|
North West
Liverpool & Wirral
|
Secretary of State for building … | Response Pending | 0/1 |
| 6 Apr 2026 |
Allan Stevenson
2026-0207
· Nigel Parsley
A traffic management plan was incorrectly implemented due to inaccurate map coordinates, leading to improper signage and a road traffic collision; special …
|
East of England
Suffolk
|
Anglican Water Core Highways Group Limited Secretary of State for Transport Suffolk County Council | Response Pending | 0/4 |
| 3 Apr 2026 |
Roman Barr
2026-0197
· Linda Lee
The report identifies limited awareness of salbutamol overuse, inconsistent identification and follow-up of reliever overuse, ambulance handover delays affecting emergency availability, risks …
|
West Midlands
Coventry
|
Asthma & Lung (for information) Care Quality Commission NHS England NHS Pathways/NHS Digital (NHS England … | No Identified Response | 0/6 |
| 2 Apr 2026 |
Peter Pettit
2026-0196
· Darren Stewart
Inadequate record keeping, poor medication management support, and deficient catheter management were identified in community care services. There were also concerns that …
|
East of England
Suffolk
|
Multi-Care Community Services Suffolk | No Identified Response | 0/1 |
| 2 Apr 2026 |
David Abbot
2026-0195
· Darren Stewart
Incorrect advice was given to a patient upon discharge from West Suffolk Hospital regarding weight bearing and mobilisation, potentially contributing to the …
|
East of England
Suffolk
|
West Suffolk NHS Foundation Trust | No Identified Response | 0/1 |
| 1 Apr 2026 |
Lucy Phelan
2026-0209
· David Reid
The use of the "latching" facility on patient monitoring equipment may contribute to alarm fatigue, making it difficult for staff to respond …
|
West Midlands
Worcestershire
|
NHS Wales NHS England Worcestershire Acute Hospital NHS Trust | No Identified Response | 0/3 |
| 1 Apr 2026 |
Susan Whittles
2026-0191
· Lorraine Harris
Nationals of non-designated countries who fail a GB driving test can continue to drive in the UK for up to 12 months …
|
Yorkshire and the Humber
East Riding and Hull
|
Department for Transport Driver and Vehicle Standards Agency | No Identified Response | 0/2 |
| 1 Apr 2026 |
Colin Foley
2026-0188
· Paul Marks
The coroner recommends that the NHS at large should be aware of issues relating to the insertion, maintenance, and documentation of intravenous …
|
Hull and East Riding
|
NHS England | All Responded | 1/1 |
| 1 Apr 2026 |
Benjamin Rowley
2026-0192
· Paul Smith
Two incidents at a dialysis centre involved the detachment of a port from a Covidien Palindrome Chronic Dual Lumen Catheter, leading to …
|
East Midlands
Greater Lincolnshire
|
Medicines and Healthcare Products Regulatory … Medtronic Limited University Hospitals of Leicester NHS … | No Identified Response | 0/3 |
| 1 Apr 2026 |
Hollie Loraine
2026-0193
· David Place
The national NHS pathways telephone triage system provides no specific guidance on whether to maintain telephone contact with a patient expressing suicidal …
|
North East
Sunderland
|
NHS England | All Responded | 1/1 |
| 31 Mar 2026 |
Raisa Iordan
2026-0190
· Charlotte Keighley
A junior doctor's concerns were ignored by a senior doctor, whose assessment was limited; out-of-hours radiology interpretation was provided by an agency …
|
Yorkshire and the Humber
West Yorkshire Western
|
Mid Yorkshire Teaching Hospital NHS … Telemedicine Clinic Limited | No Identified Response | 0/2 |
| 31 Mar 2026 |
John Hay
2026-0189
· Hassan Shah
Risk assessments in the care plan were not completed or reviewed with nursing or medical input, and the escalation process for medical …
|
East Midlands
Northamptonshire
|
CQC QCC Care Bureau West Northamptonshire Council | No Identified Response | 0/4 |
| 31 Mar 2026 |
Jack Saunders
2026-0187
· James Newman
Borrowed equipment lacked instructions, and while national carbon monoxide poisoning risk training existed, it had not reached trainers within individual troops; the …
|
North West
Lancashire with Blackburn and Darwen
|
Scouting Association | No Identified Response | 0/1 |
| 30 Mar 2026 |
John Tarrant
2026-0199
· Robert Simpson
Falls risk assessments were carried out based on incorrect data, and the Trust lacked a way of auditing their accuracy; a doctor …
|
South East
Berkshire
|
Frimley Health NHS Foundation Trust | No Identified Response | 0/1 |
| 30 Mar 2026 |
Oliver Roberts
2026-0184
· Rachael Griffins
There is a lack of practical guidance for police officers on applying their powers to obtain communications data under the Investigatory Powers …
|
South West
Dorset
|
National Police Chiefs' Council College of Policing Devon and Cornwall Police Dorset Healthcare NHS Trust | All Responded | 2/5 |
| 27 Mar 2026 |
Edith Millington
2026-0183
· Andrew Bridgman
The structure/design of the store's access ramp is unsafe, because it is not fixed to the ground, the rubber mat is not …
|
North West
Manchester South
|
Sai SKN Ltd | All Responded | 1/1 |
| 26 Mar 2026 |
Madison Smith
2026-0179
· Alison Mutch
There is no statutory regulation of agencies or individuals offering sleep routine services for young children, and anyone can attach the term …
|
North West
Manchester South
|
Department of Health and Social … | All Responded | 1/1 |
| 26 Mar 2026 |
Melanie Pinnell
2026-0185
· Daniel Sharpstone
No follow-up was offered to the deceased by the GP practice after she described suicidal ideation and suicidal thoughts; a Consultant Psychiatrist's …
|
East of England
Suffolk
|
Unity Healthcare | All Responded | 1/1 |
| 26 Mar 2026 |
Alex Ganski
2026-0180
· Joseph Turner
There was no designated lead with oversight and authority over the deceased's care, and a 'care gap' resulted in fragmented information sharing …
|
South East
West Sussex, Brighton and Hove
|
Department of Health and Social … | No Identified Response | 0/1 |
| 26 Mar 2026 |
Elizabeth Lang and Katie Lang
2026-0182
· Andrew Hetherington
Surface friction was low at the collision site, and while the council had undertaken roadworks, there was no advance warning signage alerting …
|
North East
Northumberland
|
Northumberland County Council | All Responded | 1/1 |
Joshua Perry
Response Pending
A conflict exists between Building Regulations and BSI Standards regarding the measurement of barrier heights when a wall or parapet is used as guarding, …
Secretary of State for …
Allan Stevenson
Response Pending
A traffic management plan was incorrectly implemented due to inaccurate map coordinates, leading to improper signage and a road traffic collision; special signage was …
Anglican Water
Core Highways Group Limited
Secretary of State for …
Roman Barr
No Identified Response
The report identifies limited awareness of salbutamol overuse, inconsistent identification and follow-up of reliever overuse, ambulance handover delays affecting emergency availability, risks when families …
Asthma & Lung (for …
Care Quality Commission
NHS England
Peter Pettit
No Identified Response
Inadequate record keeping, poor medication management support, and deficient catheter management were identified in community care services. There were also concerns that training inadequacies …
Multi-Care Community Services Suffolk
David Abbot
No Identified Response
Incorrect advice was given to a patient upon discharge from West Suffolk Hospital regarding weight bearing and mobilisation, potentially contributing to the development of …
West Suffolk NHS Foundation …
Lucy Phelan
No Identified Response
The use of the "latching" facility on patient monitoring equipment may contribute to alarm fatigue, making it difficult for staff to respond to different …
NHS Wales
NHS England
Worcestershire Acute Hospital NHS …
Susan Whittles
No Identified Response
Nationals of non-designated countries who fail a GB driving test can continue to drive in the UK for up to 12 months on their …
Department for Transport
Driver and Vehicle Standards …
Colin Foley
All Responded
The coroner recommends that the NHS at large should be aware of issues relating to the insertion, maintenance, and documentation of intravenous access devices, …
NHS England
Benjamin Rowley
No Identified Response
Two incidents at a dialysis centre involved the detachment of a port from a Covidien Palindrome Chronic Dual Lumen Catheter, leading to blood loss; …
Medicines and Healthcare Products …
Medtronic Limited
University Hospitals of Leicester …
Hollie Loraine
All Responded
The national NHS pathways telephone triage system provides no specific guidance on whether to maintain telephone contact with a patient expressing suicidal intent, or …
NHS England
Raisa Iordan
No Identified Response
A junior doctor's concerns were ignored by a senior doctor, whose assessment was limited; out-of-hours radiology interpretation was provided by an agency whose expertise …
Mid Yorkshire Teaching Hospital …
Telemedicine Clinic Limited
John Hay
No Identified Response
Risk assessments in the care plan were not completed or reviewed with nursing or medical input, and the escalation process for medical input was …
CQC
QCC
Care Bureau
Jack Saunders
No Identified Response
Borrowed equipment lacked instructions, and while national carbon monoxide poisoning risk training existed, it had not reached trainers within individual troops; the deceased had …
Scouting Association
John Tarrant
No Identified Response
Falls risk assessments were carried out based on incorrect data, and the Trust lacked a way of auditing their accuracy; a doctor did not …
Frimley Health NHS Foundation …
Oliver Roberts
All Responded
There is a lack of practical guidance for police officers on applying their powers to obtain communications data under the Investigatory Powers Act 2016, …
National Police Chiefs' Council
College of Policing
Devon and Cornwall Police
Edith Millington
All Responded
The structure/design of the store's access ramp is unsafe, because it is not fixed to the ground, the rubber mat is not fixed, there …
Sai SKN Ltd
Madison Smith
All Responded
There is no statutory regulation of agencies or individuals offering sleep routine services for young children, and anyone can attach the term 'nurse' to …
Department of Health and …
Melanie Pinnell
All Responded
No follow-up was offered to the deceased by the GP practice after she described suicidal ideation and suicidal thoughts; a Consultant Psychiatrist's request for …
Unity Healthcare
Alex Ganski
No Identified Response
There was no designated lead with oversight and authority over the deceased's care, and a 'care gap' resulted in fragmented information sharing and updating …
Department of Health and …
Elizabeth Lang and Katie Lang
All Responded
Surface friction was low at the collision site, and while the council had undertaken roadworks, there was no advance warning signage alerting unfamiliar drivers …
Northumberland County Council