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 22 of 317
Showing 20 at a time
| Date | Report | Region / area | Addressee(s) | Status | Responses |
|---|---|---|---|---|---|
| 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 |
| 29 Aug 2025 |
Audrey Newman
2025-0443
· Andrew Bridgman
A lack of trained ward doctors for lumbar punctures and the absence of a formal escalation pathway for assistance created significant delays …
|
North West
Manchester South
|
CEO, Stockport NHS Foundation Trust | All Responded | 1/1 |
| 28 Aug 2025 |
Edwin Price
2025-0440
· Vanessa McKinlay
A falls risk assessment was not completed within the required timeframe, failing to identify specific risks and implement mitigation measures, and no …
|
South West
Somerset
|
Somerset NHS Foundation Trust | All Responded | 1/1 |
| 28 Aug 2025 |
Kore Padgett
2025-0441
· Charlotte Keighley
There was a lack of staff training for hard collar fitting and poor communication between clinicians, leading to insufficient consideration of treatment …
|
Yorkshire and the Humber
West Yorkshire West
|
Calderdale and Huddersfield NHS Foundation … | All Responded | 1/1 |
| 26 Aug 2025 |
Gabriella Jaiyesimi
2025-0444
· Mary Hassell
Tesco staff, including duty managers, lacked basic first aid and CPR training, resulting in a failure to recognize cardiac arrest, perform life-saving …
|
London
Inner North London
|
Chief Executive Security Industry Authority … Chief Executive Tesco PLC Chief Executive Total Security Services … | All Responded | 3/3 |
| 26 Aug 2025 |
Anne Dyson
2025-0439
· David Place
Radiologists receive inconsistent and limited patient information, often focused to specific areas, risking confirmation bias and delayed diagnoses by restricting comprehensive scan …
|
North East
Sunderland
|
South Tyneside and Sunderland NHS … | All Responded | 1/1 |
| 22 Aug 2025 |
Lee Stammers
2025-0438
· Louise Slater
Poor documentation, communication, and system failures led to urgent medical tests being missed or inaccurately recorded. Unidentified temporary staff could also cancel …
|
Yorkshire and the Humber
South Yorkshire East
|
Doncaster Royal Infirmary | All Responded | 1/1 |
| 21 Aug 2025 |
Nicholas Murphy
2025-0437
· Robert Simpson
Critical information regarding a patient's refusal of treatment may be missed due to inadequate outcome codes, leading to misleading impressions and hindering …
|
South East
Hampshire, Portsmouth and Southampton
|
NHS England | All Responded | 1/1 |
| 20 Aug 2025 |
Charles Stonley
2025-0432
· Anita Bhardwaj
Limited resources and a severe shortage of mental health beds mean vulnerable patients in crisis are left in Emergency Departments for prolonged …
|
North West
Liverpool and Wirral
|
Deputy Director of Patient Safety … Health Services Safety Investigations Body … National Director FOR Mental Health NHS England Improvement (PFDs) | Partially Responded | 2/4 |
| 20 Aug 2025 |
Mary Fitzpatrick
2025-0435
· Mary Hassell
An unnecessary hospital admission and inadequate district nursing care for a pressure sore, compounded by a lack of organizational reflection, led to …
|
London
Inner North London
|
Chief Executive Whittington Health NHS … | All Responded | 1/1 |
| 20 Aug 2025 |
Masood Hamid
2025-0434
· Joanne Kearsley
There was a lack of planning for safe patient transport, particularly for a dementia patient, and an ineffective investigation into the death, …
|
North West
Manchester North
|
Chief Constable Greater Manchester Police Chief Executive North West Ambulance … Chief Executive Oldham Borough Council Chief Executive Pennine Care NHS … | All Responded | 4/4 |
| 20 Aug 2025 |
Ricky O’Connell
2025-0433
· Alison Mutch
Ambulance response times are severely impacted by significant delays in clearing emergency departments and high demand for services, exacerbated by challenges in …
|
North West
Manchester South
|
Department of Health and Social … | All Responded | 1/1 |
| 19 Aug 2025 |
Gemma Weeks
2025-0428
· Brendan Allen
Public and young people lack understanding of ketamine's severe dangers, exacerbated by its Class B classification suggesting lower risk, leading to increased …
|
South West
Dorset
|
Secretary of State for Education Secretary of State for Health … Secretary of State for the … | All Responded | 3/3 |
| 19 Aug 2025 |
Venetia Pierce
2025-0427
· Susan Ridge
An EMIS system failed to flag a nitrofurantoin safety alert because it only triggered for pre-existing conditions, alongside generally low clinician awareness …
|
South East
Surrey
|
EMIS Health Medicines and Healthcare Products Regulatory … | Partially Responded | 1/2 |
| 18 Aug 2025 |
Emily Hewerdine
2025-0431
· Elizabeth Didcock
Patients faced inadequate hydration assessments and fluid charting, nursing failures to identify deterioration, and a lack of clinical assessment in the Emergency …
|
East Midlands
Nottingham and Nottinghamshire
|
Chief Executive, Doncaster and Bassetlaw … | All Responded | 1/1 |
| 12 Aug 2025 |
Resmije Ahmetaj
2025-0424
· Sonia Hayes
Mental health services exhibited inadequate clozapine monitoring, poor communication and escalation regarding subtherapeutic medication levels, and delayed management of critical side effects, …
|
East of England
Essex
|
Basildon Car Park Management Essex Partnership NHS Foundation Trust | All Responded | 2/2 |
| 12 Aug 2025 |
James Rownsley
2025-0430
· Nicola Mundy
There is insufficient awareness and communication regarding the fire risks of emollient creams near heat, particularly for vulnerable individuals. Current reporting systems …
|
Yorkshire and the Humber
South Yorkshire East
|
National Fire Chiefs Council | All Responded | 1/1 |
| 12 Aug 2025 |
Chloe Barber
2025-0421
· Paul Marks
Critical gaps exist in transitional care pathways from CAMHS to adult services, along with unclear guidelines for administering antipsychotic depots and a …
|
Yorkshire and the Humber
City of Kingston Upon Hull and …
|
Department of Health and Social … NHS England Royal College of Psychiatrists | Partially Responded | 2/3 |
| 12 Aug 2025 |
Robert Simpson
2025-0423
· Ana Samuel
A patient was discharged with incorrect medication and missed critical antibiotic doses due to stock issues and poor communication, highlighting systemic failures …
|
West Midlands
Birmingham and Solihull
|
University Hospitals Birmingham NHS Foundation … | All Responded | 1/1 |
| 12 Aug 2025 |
Margaret Taylor
2025-0420
· Rebecca Ollivere
A patient was removed from a soft food diet without proper assessment or documentation, and external food was not checked for suitability …
|
South West
Gloucestershire
|
Oak Tree Mews Care Home | All Responded | 1/1 |
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
Audrey Newman
All Responded
A lack of trained ward doctors for lumbar punctures and the absence of a formal escalation pathway for assistance created significant delays in crucial …
CEO, Stockport NHS Foundation …
Edwin Price
All Responded
A falls risk assessment was not completed within the required timeframe, failing to identify specific risks and implement mitigation measures, and no subsequent actions …
Somerset NHS Foundation Trust
Kore Padgett
All Responded
There was a lack of staff training for hard collar fitting and poor communication between clinicians, leading to insufficient consideration of treatment options and …
Calderdale and Huddersfield NHS …
Gabriella Jaiyesimi
All Responded
Tesco staff, including duty managers, lacked basic first aid and CPR training, resulting in a failure to recognize cardiac arrest, perform life-saving actions, or …
Chief Executive Security Industry …
Chief Executive Tesco PLC
Chief Executive Total Security …
Anne Dyson
All Responded
Radiologists receive inconsistent and limited patient information, often focused to specific areas, risking confirmation bias and delayed diagnoses by restricting comprehensive scan interpretation.
South Tyneside and Sunderland …
Lee Stammers
All Responded
Poor documentation, communication, and system failures led to urgent medical tests being missed or inaccurately recorded. Unidentified temporary staff could also cancel tests without …
Doncaster Royal Infirmary
Nicholas Murphy
All Responded
Critical information regarding a patient's refusal of treatment may be missed due to inadequate outcome codes, leading to misleading impressions and hindering proper safeguarding …
NHS England
Charles Stonley
Partially Responded
Limited resources and a severe shortage of mental health beds mean vulnerable patients in crisis are left in Emergency Departments for prolonged periods, increasing …
Deputy Director of Patient …
Health Services Safety Investigations …
National Director FOR Mental …
Mary Fitzpatrick
All Responded
An unnecessary hospital admission and inadequate district nursing care for a pressure sore, compounded by a lack of organizational reflection, led to preventable harm …
Chief Executive Whittington Health …
Masood Hamid
All Responded
There was a lack of planning for safe patient transport, particularly for a dementia patient, and an ineffective investigation into the death, hindering learning …
Chief Constable Greater Manchester …
Chief Executive North West …
Chief Executive Oldham Borough …
Ricky O’Connell
All Responded
Ambulance response times are severely impacted by significant delays in clearing emergency departments and high demand for services, exacerbated by challenges in primary care …
Department of Health and …
Gemma Weeks
All Responded
Public and young people lack understanding of ketamine's severe dangers, exacerbated by its Class B classification suggesting lower risk, leading to increased usage, addiction, …
Secretary of State for …
Secretary of State for …
Secretary of State for …
Venetia Pierce
Partially Responded
An EMIS system failed to flag a nitrofurantoin safety alert because it only triggered for pre-existing conditions, alongside generally low clinician awareness of the …
EMIS Health
Medicines and Healthcare Products …
Emily Hewerdine
All Responded
Patients faced inadequate hydration assessments and fluid charting, nursing failures to identify deterioration, and a lack of clinical assessment in the Emergency Department before …
Chief Executive, Doncaster and …
Resmije Ahmetaj
All Responded
Mental health services exhibited inadequate clozapine monitoring, poor communication and escalation regarding subtherapeutic medication levels, and delayed management of critical side effects, increasing psychosis …
Basildon Car Park Management
Essex Partnership NHS Foundation …
James Rownsley
All Responded
There is insufficient awareness and communication regarding the fire risks of emollient creams near heat, particularly for vulnerable individuals. Current reporting systems for related …
National Fire Chiefs Council
Chloe Barber
Partially Responded
Critical gaps exist in transitional care pathways from CAMHS to adult services, along with unclear guidelines for administering antipsychotic depots and a poor understanding …
Department of Health and …
NHS England
Royal College of Psychiatrists
Robert Simpson
All Responded
A patient was discharged with incorrect medication and missed critical antibiotic doses due to stock issues and poor communication, highlighting systemic failures in medication …
University Hospitals Birmingham NHS …
Margaret Taylor
All Responded
A patient was removed from a soft food diet without proper assessment or documentation, and external food was not checked for suitability by care …
Oak Tree Mews Care …