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 20 of 317
Showing 20 at a time
| Date | Report | Region / area | Addressee(s) | Status | Responses |
|---|---|---|---|---|---|
| 24 Sep 2025 |
Honoria Culshaw (1)
2025-0479
· Anna Morris
Critical information regarding the need for pacemaker extraction was not adequately communicated between specialist and local hospitals, nor to the patient's GP, …
|
North West
Manchester South
|
Manchester University NHS Foundation Trust | 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 |
| 23 Sep 2025 |
Christopher Bird
2025-0477
· David Ridley
Concerns were raised about the reliability of the nhs.net email system for transmitting critical mental health information to GPs, leading to systemic …
|
South West
Wiltshire and Swindon
|
NHS England Oxford Health NHS Foundation Trust White Horse Medical Practice | Partially Responded | 2/3 |
| 23 Sep 2025 |
Tony Jackson
2025-0475
· Graeme Irvine
A fatal iatrogenic injury went undetected due to extremely poor patient records, and the Trust's governance failed to identify the case for …
|
London
East London
|
Chief Executive Officer, Barts Health … Secretary of State for Dept. … | All Responded | 2/2 |
| 19 Sep 2025 |
Kwabena Amoateng
2025-0429
· Graeme Irvine
A critically important paediatric respiratory action plan was mislabelled and misfiled in online records, preventing emergency healthcare professionals from accessing vital guidance …
|
London
East London
|
South-East London Integrated Care System Chief Nursing Officer, NHS North-East … South East London ICB National Medical Director, NHS England | No Identified Response | 0/4 |
| 19 Sep 2025 |
Luke Chatterton
2025-0470
· Andrew Harris
Significant delays in accessing advanced life support in a mental health hospital and a lack of national guidelines for managing antipsychotic-induced bowel …
|
London
South London
|
Croydon University Hospital Medicines and Healthcare Products Regulatory … Royal College of Emergency Medicine Royal College of Psychiatrists | No Identified Response | 0/6 |
| 18 Sep 2025 |
Pamela Singh
2025-0473
· Gavin Knox
There is a lack of specific practice tools for family and care staff to recognise and escalate acute health deterioration in people …
|
Wales
South Wales Central
|
Minister for Health and Social … | All Responded | 1/1 |
| 18 Sep 2025 |
Leonardo Machado
2025-0476
· Brendan Allen
A lack of oversight regarding the 'rental' of food delivery licenses to children under 18 places them in vulnerable lone-working situations, increasing …
|
South West
Dorset
|
Deliveroo Home Office Just Eats Uber Eats | All Responded | 4/4 |
| 17 Sep 2025 |
Brian Davies
2025-0631
· Aled Gruffydd
The investigation into a domestic explosion was compromised by police disposing of critical debris. There was no understanding of evidence preservation or …
|
Wales
Swansea Neath & Port Talbot
|
HSE South Wales Police | All Responded | 2/2 |
| 17 Sep 2025 |
Martin Collins
2025-0497
· Peter Taheri
The prison telephone system lacks automated monitoring for unusual call volumes and there's no system for manual oversight, leading to missed opportunities …
|
East of England
Suffolk
|
Minister of State for Prisons, … | All Responded | 1/1 |
| 17 Sep 2025 |
Keith Hankin
2025-0472
· Karen Henderson
A community urology service lacked robust clinical governance, integration with NHS services, and proper appraisal of clinicians, leading to fragmented care and …
|
South East
West Sussex, Brighton and Hove
|
Chief Executive, CQC Integrated Care Board Heath Secretary, Department of Health Hospital Manager, Goring Hall | All Responded | 5/5 |
| 16 Sep 2025 |
Hilary Chapman
2026-0111
· Simon Connolly
The updated section 17 leave policy does not reflect the new processes for discussing and prescribing leave, creating a gap between practice …
|
North East
County Durham and Darlington
|
TEWV | All Responded | 1/1 |
| 16 Sep 2025 |
John Franklin
2025-0474
· Sarah Murphy
A high-risk falls patient was discharged home before a careline pendant was confirmed as installed, with conflicting records on its provision, raising …
|
West Midlands
Worcestershire
|
Worcestershire County Council | No Identified Response | 0/1 |
| 16 Sep 2025 |
Christian Marsh Prevention of future deaths report
2025-0471
· Leila Benyounes
There is no formal system for communication, information sharing, and handover of patient data between a respite facility and the Intensive Support …
|
Yorkshire and the Humber
West Yorkshire (East)
|
Leeds and Yorkshire Partnership Foundation … Leeds Survivor-Led Crisis Service (Leeds … | All Responded | 1/2 |
| 16 Sep 2025 |
Mohammed Khan
2025-0469
· Emma Brown
Paramedics lacked mandatory training and experience in obstetric emergencies, specifically breech deliveries, and national guidelines were not adhered to, leading to delayed …
|
West Midlands
Birmingham and Solihull
|
NHS Birmingham and Solihull ICB NHS Black Country ICB NHS Coventry and Warwickshire ICB NHS Herefordshire and Worcestershire ICB | All Responded | 3/8 |
| 15 Sep 2025 |
Linda Sharp
2025-0468
· Paul Marks
Relying solely on a low Wells score is a fundamentally flawed approach to exclude deep vein thrombosis or pulmonary embolus, potentially leading …
|
Yorkshire and the Humber
East Riding and Hull
|
President of the Royal College … | All Responded | 2/1 |
| 14 Sep 2025 |
Charlotte Tetley
2025-0466
· Sarah Murphy
A patient was prematurely removed from the inpatient bed list before an appropriate daily mental health review, despite documented need for admission, …
|
North West
Cheshire
|
Cheshire and Wirral Partnership NHS … | All Responded | 1/1 |
| 14 Sep 2025 |
Charlotte Tetley
2025-0465
· Sarah Murphy
A narrow police policy interpretation requires explicit intent to end life for high-risk missing person response, while ambulance services decline calls if …
|
North West
Cheshire
|
Chief Constable of Cheshire Police | All Responded | 1/1 |
| 12 Sep 2025 |
Gareth Johnson
2025-0464
· Kerrie Burge
Deteriorating hospital infrastructure and critical care capacity issues pose a significant risk, as safeguards against moving critically ill patients may fail under …
|
Wales
South Wales Central
|
Cabinet Secretary for Health and … Chief Executive Cardiff & Vale … | All Responded | 2/2 |
| 11 Sep 2025 |
Michael Moore
2025-0463
· Samantha Goward
Persistent NHS capacity constraints are causing significant and increasing delays in cancer referrals, diagnosis, and treatment, risking patient outcomes.
|
East of England
Norfolk
|
NHS England | All Responded | 1/1 |
Honoria Culshaw (1)
All Responded
Critical information regarding the need for pacemaker extraction was not adequately communicated between specialist and local hospitals, nor to the patient's GP, delaying essential …
Manchester University NHS Foundation …
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
Christopher Bird
Partially Responded
Concerns were raised about the reliability of the nhs.net email system for transmitting critical mental health information to GPs, leading to systemic communication breakdowns …
NHS England
Oxford Health NHS Foundation …
White Horse Medical Practice
Tony Jackson
All Responded
A fatal iatrogenic injury went undetected due to extremely poor patient records, and the Trust's governance failed to identify the case for investigation, hindering …
Chief Executive Officer, Barts …
Secretary of State for …
Kwabena Amoateng
No Identified Response
A critically important paediatric respiratory action plan was mislabelled and misfiled in online records, preventing emergency healthcare professionals from accessing vital guidance for a …
South-East London Integrated Care …
Chief Nursing Officer, NHS …
South East London ICB
Luke Chatterton
No Identified Response
Significant delays in accessing advanced life support in a mental health hospital and a lack of national guidelines for managing antipsychotic-induced bowel obstruction in …
Croydon University Hospital
Medicines and Healthcare Products …
Royal College of Emergency …
Pamela Singh
All Responded
There is a lack of specific practice tools for family and care staff to recognise and escalate acute health deterioration in people with learning …
Minister for Health and …
Leonardo Machado
All Responded
A lack of oversight regarding the 'rental' of food delivery licenses to children under 18 places them in vulnerable lone-working situations, increasing their risk …
Deliveroo
Home Office
Just Eats
Brian Davies
All Responded
The investigation into a domestic explosion was compromised by police disposing of critical debris. There was no understanding of evidence preservation or protocol between …
HSE
South Wales Police
Martin Collins
All Responded
The prison telephone system lacks automated monitoring for unusual call volumes and there's no system for manual oversight, leading to missed opportunities to identify …
Minister of State for …
Keith Hankin
All Responded
A community urology service lacked robust clinical governance, integration with NHS services, and proper appraisal of clinicians, leading to fragmented care and potential detriment …
Chief Executive, CQC
Integrated Care Board
Heath Secretary, Department of …
Hilary Chapman
All Responded
The updated section 17 leave policy does not reflect the new processes for discussing and prescribing leave, creating a gap between practice and documented …
TEWV
John Franklin
No Identified Response
A high-risk falls patient was discharged home before a careline pendant was confirmed as installed, with conflicting records on its provision, raising concerns about …
Worcestershire County Council
Christian Marsh Prevention of future deaths report
All Responded
There is no formal system for communication, information sharing, and handover of patient data between a respite facility and the Intensive Support Service, creating …
Leeds and Yorkshire Partnership …
Leeds Survivor-Led Crisis Service …
Mohammed Khan
All Responded
Paramedics lacked mandatory training and experience in obstetric emergencies, specifically breech deliveries, and national guidelines were not adhered to, leading to delayed intervention during …
NHS Birmingham and Solihull …
NHS Black Country ICB
NHS Coventry and Warwickshire …
Linda Sharp
All Responded
Relying solely on a low Wells score is a fundamentally flawed approach to exclude deep vein thrombosis or pulmonary embolus, potentially leading to missed …
President of the Royal …
Charlotte Tetley
All Responded
A patient was prematurely removed from the inpatient bed list before an appropriate daily mental health review, despite documented need for admission, risking patient …
Cheshire and Wirral Partnership …
Charlotte Tetley
All Responded
A narrow police policy interpretation requires explicit intent to end life for high-risk missing person response, while ambulance services decline calls if whereabouts are …
Chief Constable of Cheshire …
Gareth Johnson
All Responded
Deteriorating hospital infrastructure and critical care capacity issues pose a significant risk, as safeguards against moving critically ill patients may fail under pressure.
Cabinet Secretary for Health …
Chief Executive Cardiff & …
Michael Moore
All Responded
Persistent NHS capacity constraints are causing significant and increasing delays in cancer referrals, diagnosis, and treatment, risking patient outcomes.
NHS England