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 21 of 317
Showing 20 at a time
| Date | Report | Region / area | Addressee(s) | Status | Responses |
|---|---|---|---|---|---|
| 10 Sep 2025 |
Air India Boeing 787
2025-0575
· Fiona Wilcox
Mortuaries demonstrate an under-appreciation of formalin dangers, lacking routine monitoring and appropriate equipment for handling highly contaminated repatriated bodies, exposing staff to …
|
London
Inner West London
|
Department of Health and Social … Departmet for Housing, Communities and … | No Identified Response | 0/2 |
| 10 Sep 2025 |
Walter Horton
2025-0462
· Nicola Mundy
Concerns include poor record keeping for falls, wound management, and handover, alongside a failure to follow aseptic techniques for wound care, increasing …
|
Yorkshire and the Humber
South Yorkshire (East)
|
Mr Nick Mallaband, Acting Chief … | All Responded | 1/1 |
| 10 Sep 2025 |
Stuart Gilchrist
2025-0460
· Lorraine Harris
Restaurants and food establishments are largely unaware of useful anti-choking devices, and there is no clear responsibility for advising them to stock …
|
Yorkshire and the Humber
East Riding of Yorkshire and Hull
|
East Riding Council Health and Safety Executive Food Standards Agency | Partially Responded | 2/3 |
| 10 Sep 2025 |
Keith Reynolds
2025-0461
· Thomas Crookes
Mechanical thrombectomy services are unavailable outside 9 am-5 pm due to insufficient neuroradiologists, posing a risk of preventable deaths for patients requiring …
|
North East
Newcastle and North Tyneside
|
Newcastle upon Tyne Hospitals NHS … | All Responded | 1/1 |
| 9 Sep 2025 |
Brian Burrows
2025-0459
· Naomi McLoughlin
Prison officers lack training and guidance on decision-making when faced with competing emergency tasks like multiple cell bells and ACCT checks, risking …
|
Yorkshire and the Humber
West Yorkshire (East)
|
Governing Governor, HMP Leeds | All Responded | 1/1 |
| 8 Sep 2025 |
Maureen Gilbert
2025-0456
· Matthew Kewley
Identified flood defence measures for Tapton Terrace were not implemented due to cost, leaving the area vulnerable to flooding and posing a …
|
East Midlands
Derby and Derbyshire
|
Environment Agency Derbyshire County Council [REDACTED], Parliamentary Under-Secretary of State … | All Responded | 3/3 |
| 8 Sep 2025 |
Mabel Williams
2025-0458
· Robert Sowersby
The Trust's patient information on birth after caesarean failed to explain uterine rupture risks, hindering informed consent, and changes following serious incidents …
|
South West
Avon
|
Chief Executive, Great Western Hospitals, … | All Responded | 1/1 |
| 8 Sep 2025 |
Mabel Williams
2025-0457
· Robert Sowersby
The RCOG information leaflet on birth options after a previous caesarean section fails to mention that uterine rupture can be fatal for …
|
South West
Avon
|
President, Royal College Obstetricians and … | All Responded | 1/1 |
| 5 Sep 2025 |
Victoria Taylor
2025-0455
· Catherine Cundy
Secondary mental health services failed to offer appropriate trauma-informed treatment pathways or initiate a multi-agency approach for a patient with acknowledged childhood …
|
Yorkshire and the Humber
North Yorkshire and York
|
Tees, Esk and Wear Valleys … | No Identified Response | 0/1 |
| 5 Sep 2025 |
James Cochrane
2025-0454
· Rebecca Connell
There is no clear guidance for mental health staff on using alternative evidence formats like video footage or on ensuring carers are …
|
East Midlands
Rutland and North Leicestershire
|
Leicestershire Partnership NHS Trust | All Responded | 1/1 |
| 4 Sep 2025 |
Khalif Mohammed
2025-0452
· Louise Hunt
West Midlands Police experienced significant delays in allocating officers to a priority case due to insufficient resources, posing a risk of future …
|
West Midlands
Birmingham and Solihull
|
Home Office | All Responded | 1/1 |
| 4 Sep 2025 |
Nicola Mulliss
2025-0453
· Thomas Crookes
A lack of policy for microbiological swabbing during wound re-suturing meant a Staphylococcus Aureus infection was not detected early, delaying crucial treatment.
|
North East
Newcastle and North Tyneside
|
Newcastle upon Tyne Hospitals NHS … | All Responded | 1/1 |
| 4 Sep 2025 |
Cheryl Edwards
2025-0449
· Geoffrey Sullivan
The 60mph speed limit on the stretch of Sarratt Road between the M25 over-bridge and Sarratt Village is too high, posing a …
|
East of England
Hertfordshire
|
Chief Executive Hertfordshire County Council | All Responded | 2/1 |
| 3 Sep 2025 |
Lucy-Anne Dyson
2025-0451
· Darren Stewart
A lack of national interface for safeguarding system communication between schools and agencies, coupled with inconsistent referral guidance, risks missed or inadequate …
|
South East
Hampshire, Portsmouth and Southampton
|
Department for Education Women and Equalities | Partially Responded | 1/2 |
| 3 Sep 2025 |
Peter Thomas
2025-0450
· Rachel Knight
The CIWA protocol is too blunt and lacks nuance for elderly or delirious patients, leading to risks of over-sedation due to clinicians …
|
Wales
South Wales Central
|
National Institute for Health and … | All Responded | 1/1 |
| 3 Sep 2025 |
Margaret Bailey
2025-0448
· Andrew Bridgman
Care agencies lack a clear triage algorithm for non-medical call handlers and carers cannot perform basic observations, hindering effective client monitoring and …
|
North West
Manchester South
|
Chief Executive, Care Quality Commission Secretary of State for Health … | All Responded | 2/2 |
| 3 Sep 2025 |
Marcia Grant
2025-0447
· Marilyn Whittle
A shortage of foster placements, combined with inadequate documentation, poor communication of risks, and a failure to assess risks to carers, led …
|
Yorkshire and the Humber
South Yorkshire (West)
|
Chief Executive, Rotherham Metropolitan Borough … Secretary of State for Education, … | All Responded | 2/2 |
| 2 Sep 2025 |
Edward Funnell
2025-0445
· Andrew Morse
Nursing staff demonstrated a lack of knowledge regarding podiatry referrals for pressure wounds and failed to follow a Tissue Viability Nurse's dressing …
|
Wales
South Wales Wales
|
Powys Teaching Health Board | All Responded | 1/1 |
| 1 Sep 2025 |
Ayan Sediqi
2026-0014
· Jayne Wilkes
Dangerous road conditions, including ungritted ice and flowing water, were not addressed despite public reports. The existing reporting systems for road faults …
|
East Midlands
Greater Lincolnshire
|
Lincolnshire County Council Lincolnshire Police National Highways Midlands region | All Responded | 3/3 |
| 1 Sep 2025 |
[REDACTED]
2025-0507
· Ian Potter
There were widespread failures in the quality, accuracy, and auditing of patient observations, including staff distraction during crucial monitoring. Concerns also persist …
|
London
Inner North London
|
East London NHS Foundation Trust | All Responded | 1/1 |
Air India Boeing 787
No Identified Response
Mortuaries demonstrate an under-appreciation of formalin dangers, lacking routine monitoring and appropriate equipment for handling highly contaminated repatriated bodies, exposing staff to severe health …
Department of Health and …
Departmet for Housing, Communities …
Walter Horton
All Responded
Concerns include poor record keeping for falls, wound management, and handover, alongside a failure to follow aseptic techniques for wound care, increasing infection risk.
Mr Nick Mallaband, Acting …
Stuart Gilchrist
Partially Responded
Restaurants and food establishments are largely unaware of useful anti-choking devices, and there is no clear responsibility for advising them to stock such potentially …
East Riding Council
Health and Safety Executive
Food Standards Agency
Keith Reynolds
All Responded
Mechanical thrombectomy services are unavailable outside 9 am-5 pm due to insufficient neuroradiologists, posing a risk of preventable deaths for patients requiring urgent treatment.
Newcastle upon Tyne Hospitals …
Brian Burrows
All Responded
Prison officers lack training and guidance on decision-making when faced with competing emergency tasks like multiple cell bells and ACCT checks, risking inadequate responses.
Governing Governor, HMP Leeds
Maureen Gilbert
All Responded
Identified flood defence measures for Tapton Terrace were not implemented due to cost, leaving the area vulnerable to flooding and posing a continued risk …
Environment Agency
Derbyshire County Council
[REDACTED], Parliamentary Under-Secretary of …
Mabel Williams
All Responded
The Trust's patient information on birth after caesarean failed to explain uterine rupture risks, hindering informed consent, and changes following serious incidents are unacceptably …
Chief Executive, Great Western …
Mabel Williams
All Responded
The RCOG information leaflet on birth options after a previous caesarean section fails to mention that uterine rupture can be fatal for mother or …
President, Royal College Obstetricians …
Victoria Taylor
No Identified Response
Secondary mental health services failed to offer appropriate trauma-informed treatment pathways or initiate a multi-agency approach for a patient with acknowledged childhood trauma and …
Tees, Esk and Wear …
James Cochrane
All Responded
There is no clear guidance for mental health staff on using alternative evidence formats like video footage or on ensuring carers are adequately equipped …
Leicestershire Partnership NHS Trust
Khalif Mohammed
All Responded
West Midlands Police experienced significant delays in allocating officers to a priority case due to insufficient resources, posing a risk of future deaths.
Home Office
Nicola Mulliss
All Responded
A lack of policy for microbiological swabbing during wound re-suturing meant a Staphylococcus Aureus infection was not detected early, delaying crucial treatment.
Newcastle upon Tyne Hospitals …
Cheryl Edwards
All Responded
The 60mph speed limit on the stretch of Sarratt Road between the M25 over-bridge and Sarratt Village is too high, posing a road safety …
Chief Executive Hertfordshire County …
Lucy-Anne Dyson
Partially Responded
A lack of national interface for safeguarding system communication between schools and agencies, coupled with inconsistent referral guidance, risks missed or inadequate child protection …
Department for Education
Women and Equalities
Peter Thomas
All Responded
The CIWA protocol is too blunt and lacks nuance for elderly or delirious patients, leading to risks of over-sedation due to clinicians applying it …
National Institute for Health …
Margaret Bailey
All Responded
Care agencies lack a clear triage algorithm for non-medical call handlers and carers cannot perform basic observations, hindering effective client monitoring and response to …
Chief Executive, Care Quality …
Secretary of State for …
Marcia Grant
All Responded
A shortage of foster placements, combined with inadequate documentation, poor communication of risks, and a failure to assess risks to carers, led to an …
Chief Executive, Rotherham Metropolitan …
Secretary of State for …
Edward Funnell
All Responded
Nursing staff demonstrated a lack of knowledge regarding podiatry referrals for pressure wounds and failed to follow a Tissue Viability Nurse's dressing recommendations, leading …
Powys Teaching Health Board
Ayan Sediqi
All Responded
Dangerous road conditions, including ungritted ice and flowing water, were not addressed despite public reports. The existing reporting systems for road faults were unclear …
Lincolnshire County Council
Lincolnshire Police
National Highways Midlands region
[REDACTED]
All Responded
There were widespread failures in the quality, accuracy, and auditing of patient observations, including staff distraction during crucial monitoring. Concerns also persist regarding the …
East London NHS Foundation …