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 5 of 317
Showing 20 at a time
| Date | Report | Region / area | Addressee(s) | Status | Responses |
|---|---|---|---|---|---|
| 9 Mar 2026 |
Terrence Frost
2026-0135
· Nigel Parsley
GPs and internal hospital staff experienced significant difficulties contacting the Medical Assessment Unit and A&E to pre-alert them about seriously unwell patients, …
|
East of England
Suffolk
|
East Suffolk & North Essex … | All Responded | 1/1 |
| 6 Mar 2026 |
Asher Blackman
2026-0133
· Andrew Walker
District Nurses failed to record next of kin details and the 'no access' policy was inadequate, lacking provision for police involvement when …
|
London
North London
|
Central London Community Healthcare NHS … | All Responded | 1/1 |
| 6 Mar 2026 |
Alan Tomlinson
2026-0131
· Martin Lanchester
A pacemaker clinic failed to refer a visibly unwell patient with high thresholds to cardiology, contributed to a delayed diagnosis. Concerns include …
|
Wales
Gwent
|
Cardiff and Vale University Health … | All Responded | 1/1 |
| 6 Mar 2026 |
Kay Wilson
2026-0132
· Jeremy Chipperfield
An unguarded breach in a stone wall provides unrestricted public access to a dangerous 9-meter vertical drop onto rocks and the river …
|
North East
County Durham and Darlington
|
Durham County Council | All Responded | 1/1 |
| 5 Mar 2026 |
Caroline Adeyelu
2026-0129
· Nadia Persaud
Mental health services demonstrated a poor appreciation of risks from an adult child's mental illness to a parent, due to insufficient safeguarding …
|
London
East London
|
East London Foundation Trust Metroplolis North East London Foundation Trust | No Identified Response | 0/3 |
| 5 Mar 2026 |
Joanna Hillard
2026-0128
· Samantha Marsh
The Mental Capacity Act 2005 and current understanding fail to adequately recognise how controlling and coercive behaviour can impair a person's decision-making …
|
South West
Somerset
|
Department of Health and Social … | All Responded | 1/1 |
| 4 Mar 2026 |
Mark Hughes
2026-0123
· Benjamin Myers
Systemic delays in urgent mental health referrals to Home Based Treatment Teams, combined with the inability of general practice professionals to make …
|
North West
Manchester South
|
Greater Manchester Mental Health NHS … | All Responded | 1/1 |
| 4 Mar 2026 |
Viviana-Ray Butnaru
2026-0122
· Jyoti Gill
A lack of national guidelines exists for assessing paediatric heart conditions like myocarditis, coupled with insufficient awareness of Parvovirus. Locally, critical radiology …
|
East of England
Essex
|
Basildon Hospital (Mid & South … Royal College of Paediatrics and … | Partially Responded | 1/2 |
| 4 Mar 2026 |
Oriel Vasey
2026-0124
· Abigial Combes
An unchanged ICB form, intended for financial decisions, incorrectly includes an allergy section. This led to inaccurate clinical records and suboptimal patient …
|
North East
Sunderland
|
NHS North East and North … | All Responded | 1/1 |
| 4 Mar 2026 |
Roman Barr
2026-0148
· Linda Lee
Concerns include poor patient awareness and clinical follow-up for salbutamol overuse, prolonged ambulance handover delays impacting emergency availability, and unclear NHS Pathways …
|
West Midlands
Coventry
|
Asthma & Lung Care Quality Commission Department of Health and Social … NHS England | Partially Responded | 3/6 |
| 3 Mar 2026 |
Mujahid Adam
2026-0125
· Edwin Buckett
Inaccurate, non-contemporaneous recording of prisoner observations and an unclear definition of what constitutes an "observation" were identified. A disrepaired special cell, used …
|
London
Inner North London
|
HMP Pentonville HMPPS Ministry for Justice | Partially Responded | 1/3 |
| 3 Mar 2026 |
Wendy Boddington
2026-0121
· Peter Nieto
A significant number of patients on long-term, high-dose opiate/opioid prescriptions lack support to reduce or stop medication. There is an absence of …
|
East Midlands
Derby and Derbyshire
|
NHS Derby and Derbyshire Integrated … | All Responded | 1/1 |
| 2 Mar 2026 |
Susan Samson
2026-0120
· Rebecca Sutton
Excessive delays by the council in fitting a requested second banister rail in a tenant's home exposed the individual to a prolonged, …
|
North East
County Durham and Darlington
|
Darlington Borough Council | No Identified Response | 0/1 |
| 27 Feb 2026 |
Maisie Almond
2026-0119
· Adrian Farrow
A national shortage of donor livers, particularly for "super urgent" children, is exacerbated by clinical guidance. This has led to extended waiting …
|
North West
Manchester South
|
Department of Health and Social … NHS Blood and Transplant Service | All Responded | 2/2 |
| 27 Feb 2026 |
David Fenn
2026-0145
· Lincoln Brookes
Sepsis was not recognised or managed correctly, consultant review was delayed and hampered by poor communication, and junior staff felt unable to …
|
East of England
Essex
|
Colchester General Hospital East Suffolk and North Essex … | Partially Responded | 1/2 |
| 27 Feb 2026 |
Summer Mant
2026-0118
· Rachel Knight
A delay in obtaining adrenaline during resuscitation occurred due to non-standardised paediatric crash trolleys across hospitals, hindering junior doctors in a time-critical …
|
Wales
South Wales Central
|
Aneurin Bevan University Health Board Betsi Cadwaladr University Health Board Cabinet Secretary for Health and … Cardiff & Vale University Health … | No Identified Response | 0/10 |
| 27 Feb 2026 |
Brema Virgo
2026-0126
· Frazer Stuart
Flawed methods for assessing pavement defect heights result in relevant hazards not being identified and remedial action not being taken, creating a …
|
Wales
Gwent
|
Newport City Council – Highways | No Identified Response | 0/1 |
| 27 Feb 2026 |
Louis Saunders
2026-0130
· Laura Bradford
Poor communication and coordination between private ADHD clinics and NHS GPs led to duplicate prescriptions for different medications, risking patient confusion and …
|
South East
East Sussex
|
NHS England | All Responded | 1/1 |
| 26 Feb 2026 |
Yunus Hoque
2026-0113
· Benjamin Myers
NWAS failed to communicate significant ambulance delays to callers, even when a patient's condition deteriorated from Category 2 to 1. This lack …
|
North West
Manchester South
|
North West Ambulance Service | All Responded | 1/1 |
| 26 Feb 2026 |
William Webb
2026-0117
· Victoria Davies
A canal near student accommodation lacks safety equipment and warning signage, making it difficult for inebriated individuals to exit the water if …
|
North West
Cheshire
|
Canal & River Trust | No Identified Response | 0/1 |
Terrence Frost
All Responded
GPs and internal hospital staff experienced significant difficulties contacting the Medical Assessment Unit and A&E to pre-alert them about seriously unwell patients, causing dangerous …
East Suffolk & North …
Asher Blackman
All Responded
District Nurses failed to record next of kin details and the 'no access' policy was inadequate, lacking provision for police involvement when a patient's …
Central London Community Healthcare …
Alan Tomlinson
All Responded
A pacemaker clinic failed to refer a visibly unwell patient with high thresholds to cardiology, contributed to a delayed diagnosis. Concerns include lack of …
Cardiff and Vale University …
Kay Wilson
All Responded
An unguarded breach in a stone wall provides unrestricted public access to a dangerous 9-meter vertical drop onto rocks and the river below.
Durham County Council
Caroline Adeyelu
No Identified Response
Mental health services demonstrated a poor appreciation of risks from an adult child's mental illness to a parent, due to insufficient safeguarding training and …
East London Foundation Trust
Metroplolis
North East London Foundation …
Joanna Hillard
All Responded
The Mental Capacity Act 2005 and current understanding fail to adequately recognise how controlling and coercive behaviour can impair a person's decision-making ability.
Department of Health and …
Mark Hughes
All Responded
Systemic delays in urgent mental health referrals to Home Based Treatment Teams, combined with the inability of general practice professionals to make direct referrals …
Greater Manchester Mental Health …
Viviana-Ray Butnaru
Partially Responded
A lack of national guidelines exists for assessing paediatric heart conditions like myocarditis, coupled with insufficient awareness of Parvovirus. Locally, critical radiology reports were …
Basildon Hospital (Mid & …
Royal College of Paediatrics …
Oriel Vasey
All Responded
An unchanged ICB form, intended for financial decisions, incorrectly includes an allergy section. This led to inaccurate clinical records and suboptimal patient care, with …
NHS North East and …
Roman Barr
Partially Responded
Concerns include poor patient awareness and clinical follow-up for salbutamol overuse, prolonged ambulance handover delays impacting emergency availability, and unclear NHS Pathways triage questions.
Asthma & Lung
Care Quality Commission
Department of Health and …
Mujahid Adam
Partially Responded
Inaccurate, non-contemporaneous recording of prisoner observations and an unclear definition of what constitutes an "observation" were identified. A disrepaired special cell, used for vulnerable …
HMP Pentonville
HMPPS
Ministry for Justice
Wendy Boddington
All Responded
A significant number of patients on long-term, high-dose opiate/opioid prescriptions lack support to reduce or stop medication. There is an absence of specialist services …
NHS Derby and Derbyshire …
Susan Samson
No Identified Response
Excessive delays by the council in fitting a requested second banister rail in a tenant's home exposed the individual to a prolonged, avoidable risk …
Darlington Borough Council
Maisie Almond
All Responded
A national shortage of donor livers, particularly for "super urgent" children, is exacerbated by clinical guidance. This has led to extended waiting times, significantly …
Department of Health and …
NHS Blood and Transplant …
David Fenn
Partially Responded
Sepsis was not recognised or managed correctly, consultant review was delayed and hampered by poor communication, and junior staff felt unable to challenge decisions, …
Colchester General Hospital
East Suffolk and North …
Summer Mant
No Identified Response
A delay in obtaining adrenaline during resuscitation occurred due to non-standardised paediatric crash trolleys across hospitals, hindering junior doctors in a time-critical situation.
Aneurin Bevan University Health …
Betsi Cadwaladr University Health …
Cabinet Secretary for Health …
Brema Virgo
No Identified Response
Flawed methods for assessing pavement defect heights result in relevant hazards not being identified and remedial action not being taken, creating a risk of …
Newport City Council – …
Louis Saunders
All Responded
Poor communication and coordination between private ADHD clinics and NHS GPs led to duplicate prescriptions for different medications, risking patient confusion and potential harm.
NHS England
Yunus Hoque
All Responded
NWAS failed to communicate significant ambulance delays to callers, even when a patient's condition deteriorated from Category 2 to 1. This lack of follow-up …
North West Ambulance Service
William Webb
No Identified Response
A canal near student accommodation lacks safety equipment and warning signage, making it difficult for inebriated individuals to exit the water if they fall …
Canal & River Trust