Prevention of Future Deaths Reports

Judiciary

Browse 6,327 coroners' Regulation 28 reports by year, region, organisation, category, or keyword.

Data sourced from judiciary.uk under the Open Government Licence.

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6,327 reports · Page 3 of 317
Showing 20 at a time
Date Report Region / area Addressee(s) Status Responses
25 Mar 2026 [REDACTED]
2026-0178 · Fiona Wilcox
Child death investigation teams may be too easily reassured by well-presented homes, leading to perfunctory scene examinations and lost forensic opportunities.
London
Inner West London
 College of Policing Haleon UK Trading Limited Metropolis National Crime Agency Response Pending 0/4
24 Mar 2026 Thomas Ruggiero
2026-0172 · Ian Potter
Key issues include a vulnerable cell bell system that can be silenced externally, staff failing to complete critical ACCT documentation, and confusion …
Ian Potter
 HMP Swaleside No Identified Response 0/1
24 Mar 2026 Robert Day
2026-0169 · Ian Potter
Frontline emergency services lack national guidance for managing complex, time-critical mental health crises where existing legal powers may be insufficient or unclear, …
South East
Kent and Medway
 Department for Women’s Health and … Department of Health and Social … Home Office No Identified Response 0/3
24 Mar 2026 Thomas Ruggiero
2026-0171 · Ian Potter
Healthcare team, particularly mental health staff, inconsistently attended ACCT reviews, leaving vulnerable prisoners without adequate safety netting and protective measures.
Ian Potter
 Oxlease NHS Foundation Trust No Identified Response 0/1
24 Mar 2026 Ronald Meikle
2026-0168 · Sean Cummings
Key concerns include widespread availability of illicit drugs, inconsistent response to intoxication, fragmented information sharing, blocked observation panels, and inadequate support for …
South East
Milton Keynes
 Central & North West London … Chief Inspector of Prisons HMPPS HMP Woodhill No Identified Response 0/6
24 Mar 2026 Thomas Ruggiero
2026-0170 · Ian Potter
Widespread reliance on inexperienced, probationary prison officers across the prison estate leads to poor communication, lack of control, and increased risk of …
Ian Potter
 Department for Prison, Probation and … No Identified Response 0/1
23 Mar 2026 Richard Hopkins
2026-0155 · Linda Lee
An unrecognised proximity risk exists from sudden, unexpected failure of pressurised air suspension systems during undisturbed visual inspections, unsupported by current guidance …
West Midlands
Coventry and Warwickshire
 Driver and Vehicle Standard Agency Health and Safety Executive Society of Motor Manufacturers and … Partially Responded 2/3
23 Mar 2026 Peter Coates
2026-0154 · Paul Appleton
There is a critical gap in ambulance response categories, as some patients requiring an immediate response to prevent life-threatening deterioration do not …
North East
Teesside and Hartlepool
 NHS England All Responded 1/1
20 Mar 2026 Luke Ashcroft
2026-0159 · Paul Smith
Corded telephones in CSU cells pose a clear self-harm risk when suspended, and unreliable provision of telephone access prevents prisoners in crisis …
East Midlands
Lincolnshire
 HMP Lincoln Ministry of Justice No Identified Response 0/2
20 Mar 2026 Lee Adams
2026-0157 · Julian Morris
Doctors, particularly GPs, require greater awareness of propranolol's high toxicity at small doses and the lack of a specific antidote for overdose.
London
Inner South London
 Medicines and Healthcare products Regulatory … No Identified Response 0/1
20 Mar 2026 Lee Adams
2026-0156 · Julian Morris
GPs need greater awareness of propranolol's high toxicity at small doses, its lack of antidote, and the need to proactively inquire about …
London
Inner South London
 Royal College of General Practitioners No Identified Response 0/1
19 Mar 2026 Graham Oxley
2026-0160 · Carl Fitch
Unreliable systems for immunotherapy toxicity mean urgent oncology advice is delayed by triage, and patient alert cards do not trigger a dedicated …
South Yorkshire
 Sheffield Teaching Hospital NHS Foundation … All Responded 1/1
19 Mar 2026 Paul Nash
2026-0161 · Emma Whitting
A GP surgery failed to prioritise urgent seizure medication, and epilepsy patients nationally face difficulties obtaining sufficient quantities, leading to poor seizure …
East of England
Bedfordshire and Luton
 Department of Health and Social … Sundon Medical Centre All Responded 2/2
19 Mar 2026 James Coates
2026-0168-wp121078 · Robert Cohen
The current system relies inadequately on drivers self-reporting medical conditions to the DVLA, as doctors are not required to report, risking unreviewed …
North West
Cumbria
 Department for Transport No Identified Response 0/1
19 Mar 2026 John Fisher
2026-0166 · Karen Taylor
Poor information transfer between healthcare teams, inaccurate medication records, and inadequate handovers between care providers risk patients receiving incorrect or missed essential …
South East
West Sussex, Brighton and Hove
 Coastal Homecare Sussex Community NHS Foundation Trust All Responded 2/2
19 Mar 2026 John Beagley
2026-0158 · Roland Wooderson
A national shortage of maxillofacial surgeons, exacerbated by unfunded training elements, is impacting patient care and deterring prospective candidates.
South West
Gloucestershire
 Department of Health and Social … All Responded 1/1
18 Mar 2026 Clare Dupree
2026-0181 · M Vision
In-cell automatic fire detection is still to be fully implemented at Eastwood Park prison and across a number of prisons in the …
South West
Avon
 Director General Operations Ministry of Justice No Identified Response 0/2
18 Mar 2026 Edna Wiggett
2026-0163 · Robin Weyell
Ambulance dispatch was delayed due to a failure to re-triage and re-classify a patient's case after receiving updated information about increased pain.
East of England
Norfolk
 East of England Ambulance NHS … All Responded 1/1
18 Mar 2026 Julie Pytches
2026-0164 · Sonia Hayes
Issues included unshared anaesthetist limitations, staff confusion over emergency protocols and local variations, and unclear procedures for ambulance calls to private hospitals.
East of England
Essex
 Nuffield Health All Responded 1/1
17 Mar 2026 Delwyn Preece
2026-0165 · Louise Slater
Ward leave was granted without mental state exams or risk assessments, and medical records suffered from poor detail and unacknowledged retrospective entries, …
Yorkshire and the Humber
South Yorkshire East
 Rotherham Doncaster South Humber NHS … All Responded 1/1
[REDACTED] Response Pending
25 Mar 2026 London 0/4 responses
Child death investigation teams may be too easily reassured by well-presented homes, leading to perfunctory scene examinations and lost forensic opportunities.
College of Policing Haleon UK Trading Limited Metropolis
Thomas Ruggiero No Identified Response
24 Mar 2026 0/1 responses
Key issues include a vulnerable cell bell system that can be silenced externally, staff failing to complete critical ACCT documentation, and confusion regarding emergency …
HMP Swaleside
Robert Day No Identified Response
24 Mar 2026 South East 0/3 responses
Frontline emergency services lack national guidance for managing complex, time-critical mental health crises where existing legal powers may be insufficient or unclear, risking patient …
Department for Women’s Health … Department of Health and … Home Office
Thomas Ruggiero No Identified Response
24 Mar 2026 0/1 responses
Healthcare team, particularly mental health staff, inconsistently attended ACCT reviews, leaving vulnerable prisoners without adequate safety netting and protective measures.
Oxlease NHS Foundation Trust
Ronald Meikle No Identified Response
24 Mar 2026 South East 0/6 responses
Key concerns include widespread availability of illicit drugs, inconsistent response to intoxication, fragmented information sharing, blocked observation panels, and inadequate support for vulnerable prisoners.
Central & North West … Chief Inspector of Prisons HMPPS
Thomas Ruggiero No Identified Response
24 Mar 2026 0/1 responses
Widespread reliance on inexperienced, probationary prison officers across the prison estate leads to poor communication, lack of control, and increased risk of deaths in …
Department for Prison, Probation …
Richard Hopkins Partially Responded
23 Mar 2026 West Midlands 2/3 responses
An unrecognised proximity risk exists from sudden, unexpected failure of pressurised air suspension systems during undisturbed visual inspections, unsupported by current guidance or sector …
Driver and Vehicle Standard … Health and Safety Executive Society of Motor Manufacturers …
Peter Coates All Responded
23 Mar 2026 North East 1/1 responses
There is a critical gap in ambulance response categories, as some patients requiring an immediate response to prevent life-threatening deterioration do not meet Category …
NHS England
Luke Ashcroft No Identified Response
20 Mar 2026 East Midlands 0/2 responses
Corded telephones in CSU cells pose a clear self-harm risk when suspended, and unreliable provision of telephone access prevents prisoners in crisis from reaching …
HMP Lincoln Ministry of Justice
Lee Adams No Identified Response
20 Mar 2026 London 0/1 responses
Doctors, particularly GPs, require greater awareness of propranolol's high toxicity at small doses and the lack of a specific antidote for overdose.
Medicines and Healthcare products …
Lee Adams No Identified Response
20 Mar 2026 London 0/1 responses
GPs need greater awareness of propranolol's high toxicity at small doses, its lack of antidote, and the need to proactively inquire about patients' gambling …
Royal College of General …
Graham Oxley All Responded
19 Mar 2026 1/1 responses
Unreliable systems for immunotherapy toxicity mean urgent oncology advice is delayed by triage, and patient alert cards do not trigger a dedicated fast-track pathway …
Sheffield Teaching Hospital NHS …
Paul Nash All Responded
19 Mar 2026 East of England 2/2 responses
A GP surgery failed to prioritise urgent seizure medication, and epilepsy patients nationally face difficulties obtaining sufficient quantities, leading to poor seizure control and …
Department of Health and … Sundon Medical Centre
James Coates No Identified Response
19 Mar 2026 North West 0/1 responses
The current system relies inadequately on drivers self-reporting medical conditions to the DVLA, as doctors are not required to report, risking unreviewed licenses for …
Department for Transport
John Fisher All Responded
19 Mar 2026 South East 2/2 responses
Poor information transfer between healthcare teams, inaccurate medication records, and inadequate handovers between care providers risk patients receiving incorrect or missed essential medication.
Coastal Homecare Sussex Community NHS Foundation …
John Beagley All Responded
19 Mar 2026 South West 1/1 responses
A national shortage of maxillofacial surgeons, exacerbated by unfunded training elements, is impacting patient care and deterring prospective candidates.
Department of Health and …
Clare Dupree No Identified Response
18 Mar 2026 South West 0/2 responses
In-cell automatic fire detection is still to be fully implemented at Eastwood Park prison and across a number of prisons in the wider prison …
Director General Operations Ministry of Justice
Edna Wiggett All Responded
18 Mar 2026 East of England 1/1 responses
Ambulance dispatch was delayed due to a failure to re-triage and re-classify a patient's case after receiving updated information about increased pain.
East of England Ambulance …
Julie Pytches All Responded
18 Mar 2026 East of England 1/1 responses
Issues included unshared anaesthetist limitations, staff confusion over emergency protocols and local variations, and unclear procedures for ambulance calls to private hospitals.
Nuffield Health
Delwyn Preece All Responded
17 Mar 2026 Yorkshire and the Humber 1/1 responses
Ward leave was granted without mental state exams or risk assessments, and medical records suffered from poor detail and unacknowledged retrospective entries, hindering effective …
Rotherham Doncaster South Humber …