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 4 of 317
Showing 20 at a time
| Date | Report | Region / area | Addressee(s) | Status | Responses |
|---|---|---|---|---|---|
| 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 |
| 16 Mar 2026 |
Darren Dickson
2026-0150
· Andrew Cousins
Poor record-keeping meant that information and signposting provided to the patient were unclear, and inadequate communication between services led to conflicting advice …
|
North West
Cumbria
|
Recovery Steps | All Responded | 1/1 |
| 16 Mar 2026 |
Jardine Williams
2026-0173
· Andrew Cousins
The 999 call pathway for mental health crises lacks a specific question to assess the immediacy of a stated suicide plan, potentially …
|
North West
Cumbria
|
NHS England | No Identified Response | 0/1 |
| 16 Mar 2026 |
Darren Dickson
2026-0150-wp120381
· Andrew Cousins
Inadequate policies allowed supervision records to be overwritten and subsequently destroyed, preventing accurate ascertainment of information and raising concerns about proper record …
|
North West
Cumbria
|
Cumbria, Northumberland, Tyne & Wear … | All Responded | 1/1 |
| 16 Mar 2026 |
Jardine Williams
2026-0173-wp121101
· Andrew Cousins
Communication between NWAS and CHOC was unclear, resulting in limited information transfer and significant delays in CHOC returning calls to NWAS after …
|
North West
Cumbria
|
Northwest Ambulance Service | No Identified Response | 0/1 |
| 15 Mar 2026 |
Ruslans Burkevics
2026-0175
· Michael Pemberton
Front line police officers receive regular refresher training on first aid, but no similar provision is in place for mental health first …
|
North West
Manchester West
|
Greater Manchester Police | Response Pending | 0/1 |
| 12 Mar 2026 |
Tania Jarman
2026-0143
· Elizabeth Wheeler
Persistent shortage of mental health beds risks lives, and clinicians may apply an artificially high threshold for admission due to system pressures.
|
North West
Cheshire
|
Department of Health and Social … | No Identified Response | 0/1 |
| 12 Mar 2026 |
Paul Green
2026-0146
· Gareth Jones
The current system allows inexperienced 17-year-old drivers to drive unsupervised with teenage passengers, which is a factor in collisions and increases the …
|
South East
West Sussex, Brighton and Hove
|
Department for Transport | All Responded | 1/1 |
| 11 Mar 2026 |
Peter Campbell
2026-0211
· Mary Hassell
Drugs are rife within Pentonville prison, and there was a failure by the prison drug service to provide a meaningful interaction with …
|
London
Inner North London
|
HM Prison Pentonville HM Prison & Probation Service Phoenix Futures Practice Plus Group | All Responded | 4/4 |
| 11 Mar 2026 |
Janette Palmer
2026-0140
· Nigel Parsley
A housing association was unaware of the UK Power Networks Priority Services Register, risking vulnerable residents not receiving enhanced support during power …
|
East of England
Suffolk
|
Department of Health and Social … | All Responded | 1/1 |
| 11 Mar 2026 |
Mark Simpson
2026-0139
· Alan Wilson
NHS 111 reports to GP practices are not always reviewed by medically qualified staff, and critical information is often not added to …
|
North West
Blackpool & Fylde
|
Department of Health and Social … Royal College of General Practitioners | All Responded | 2/2 |
| 11 Mar 2026 |
Malcolm Welch
2026-0144
· Mark Armitage
Inconsistent provision of mobility aids during patient transfers between hospital wards, as walking frames do not automatically follow patients, posing a fall …
|
Yorkshire and the Humber
North Yorkshire and York
|
York & Scarborough Teaching Hospitals … | All Responded | 1/1 |
| 11 Mar 2026 |
Charlotte Jones
2026-0149
· Kirsty Gomersal
Information sharing procedures between different health services are inadequate, failing to ensure the proper exchange of service user information regardless of treatment …
|
North West
Cumbria
|
Cumbria, Northumberland, Tyne & Wear … Recovery Steps Cumbria | Partially Responded | 1/2 |
| 10 Mar 2026 |
Darryl Johnson
2026-0152
· Emma Whitting
Inaccurate and outdated address information in the ambulance service's mapping database, even for long-established properties, created delays in emergency response, risking patient …
|
East of England
Bedfordshire and Luton
|
Ordnance Survey | All Responded | 1/1 |
| 10 Mar 2026 |
Ruairi Stewart
2026-0138
· Elizabeth Wheeler
Failures include inadequate MDT input and inaccurate reports, lack of accountability for drug testing, poor documentation of leave decisions and substance misuse, …
|
North West
Cheshire
|
Alternative Futures Group | All Responded | 1/1 |
| 10 Mar 2026 |
John Loannou
2026-0137
· Graeme Irvine
Barts Health Trust failed to investigate a patient's death under the NHS Patient Safety Framework, missing crucial learning opportunities regarding infection causes …
|
London
East London
|
Barts Health NHS Trust Department of Health and Social … | No Identified Response | 0/2 |
| 10 Mar 2026 |
Jennine Romeo
2026-0142
· Alison Hewitt
A critical echocardiogram result was not reviewed by a clinician for months, as no system ensured timely review when appointments were cancelled, …
|
London
City of London
|
North Middlesex university Hospital Royal Free London NHS Foundation … | All Responded | 1/2 |
| 10 Mar 2026 |
Sheila Creegan
2026-0147
· Graeme Irvine
The Trust failed to conduct a proper patient safety investigation into the death despite clear errors, including an inaccurate initial cause of …
|
London
East London
|
Barking, Havering and Redbridge University … Department of Health and Social … | No Identified Response | 0/2 |
| 10 Mar 2026 |
Surendrakumar Patel
2026-0141
· James Puzey
Healthcare staff lacked awareness of the food refusal policy and failed to conduct necessary mental capacity assessments for patients refusing food.
|
West Midlands
Worcestershire
|
Government Legal Department Midlands Partnership NHS Foundation Trust Practice Plus Group | No Identified Response | 0/3 |
| 9 Mar 2026 |
Taylor Maddox
2026-0136
· Stephen Covell
Psychiatric patients discharged from hospital face inadequate housing support due to poor communication with housing services and assessment processes that do not …
|
South West
Devon, Plymouth and Torbay
|
North Devon Council | All Responded | 1/1 |
Delwyn Preece
All Responded
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 …
Darren Dickson
All Responded
Poor record-keeping meant that information and signposting provided to the patient were unclear, and inadequate communication between services led to conflicting advice regarding benzodiazepine …
Recovery Steps
Jardine Williams
No Identified Response
The 999 call pathway for mental health crises lacks a specific question to assess the immediacy of a stated suicide plan, potentially hindering call …
NHS England
Darren Dickson
All Responded
Inadequate policies allowed supervision records to be overwritten and subsequently destroyed, preventing accurate ascertainment of information and raising concerns about proper record retention.
Cumbria, Northumberland, Tyne & …
Jardine Williams
No Identified Response
Communication between NWAS and CHOC was unclear, resulting in limited information transfer and significant delays in CHOC returning calls to NWAS after multiple unsuccessful …
Northwest Ambulance Service
Ruslans Burkevics
Response Pending
Front line police officers receive regular refresher training on first aid, but no similar provision is in place for mental health first aid training.
Greater Manchester Police
Tania Jarman
No Identified Response
Persistent shortage of mental health beds risks lives, and clinicians may apply an artificially high threshold for admission due to system pressures.
Department of Health and …
Paul Green
All Responded
The current system allows inexperienced 17-year-old drivers to drive unsupervised with teenage passengers, which is a factor in collisions and increases the risk of …
Department for Transport
Peter Campbell
All Responded
Drugs are rife within Pentonville prison, and there was a failure by the prison drug service to provide a meaningful interaction with the deceased …
HM Prison Pentonville
HM Prison & Probation …
Phoenix Futures
Janette Palmer
All Responded
A housing association was unaware of the UK Power Networks Priority Services Register, risking vulnerable residents not receiving enhanced support during power outages.
Department of Health and …
Mark Simpson
All Responded
NHS 111 reports to GP practices are not always reviewed by medically qualified staff, and critical information is often not added to patients' medical …
Department of Health and …
Royal College of General …
Malcolm Welch
All Responded
Inconsistent provision of mobility aids during patient transfers between hospital wards, as walking frames do not automatically follow patients, posing a fall risk.
York & Scarborough Teaching …
Charlotte Jones
Partially Responded
Information sharing procedures between different health services are inadequate, failing to ensure the proper exchange of service user information regardless of treatment pathway, which …
Cumbria, Northumberland, Tyne & …
Recovery Steps Cumbria
Darryl Johnson
All Responded
Inaccurate and outdated address information in the ambulance service's mapping database, even for long-established properties, created delays in emergency response, risking patient outcomes.
Ordnance Survey
Ruairi Stewart
All Responded
Failures include inadequate MDT input and inaccurate reports, lack of accountability for drug testing, poor documentation of leave decisions and substance misuse, and a …
Alternative Futures Group
John Loannou
No Identified Response
Barts Health Trust failed to investigate a patient's death under the NHS Patient Safety Framework, missing crucial learning opportunities regarding infection causes and communication …
Barts Health NHS Trust
Department of Health and …
Jennine Romeo
All Responded
A critical echocardiogram result was not reviewed by a clinician for months, as no system ensured timely review when appointments were cancelled, and no …
North Middlesex university Hospital
Royal Free London NHS …
Sheila Creegan
No Identified Response
The Trust failed to conduct a proper patient safety investigation into the death despite clear errors, including an inaccurate initial cause of death and …
Barking, Havering and Redbridge …
Department of Health and …
Surendrakumar Patel
No Identified Response
Healthcare staff lacked awareness of the food refusal policy and failed to conduct necessary mental capacity assessments for patients refusing food.
Government Legal Department
Midlands Partnership NHS Foundation …
Practice Plus Group
Taylor Maddox
All Responded
Psychiatric patients discharged from hospital face inadequate housing support due to poor communication with housing services and assessment processes that do not sufficiently account …
North Devon Council