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 6 of 317
Showing 20 at a time
| Date | Report | Region / area | Addressee(s) | Status | Responses |
|---|---|---|---|---|---|
| 25 Feb 2026 |
Urmila Patel
2026-0116
· Graeme Irvine
Nursing failures included inadequate falls risk assessment, poor care-planning, and insufficient monitoring. Doctors also failed to decisively assess for intracranial bleeding or …
|
London
East London
|
Barts Health NHS Trust Department of Health and Social … | No Identified Response | 0/2 |
| 25 Feb 2026 |
Lesley Krommendijk
2026-0109
· Jyoti Gill
Discharge assessment processes led to an unrealistic impression of the patient's mobility, potentially compromising patient safety.
|
North West
Manchester South
|
Stockport NHS Foundation Trust | All Responded | 1/1 |
| 25 Feb 2026 |
Raymond Moran
2026-0108
· Paul Marks
The falls risk assessment was inaccurate, not updated, and documentation was incomplete.
|
Yorkshire and the Humber
City of Kingston Upon Hull and …
|
HUTH | No Identified Response | 0/1 |
| 25 Feb 2026 |
Emma Turner
2026-0115
· Sabyta Kaushal
Poor information sharing and lack of system connectivity between agencies hindered care for a vulnerable adult. The GP safeguarding referral form was …
|
East Midlands
Derby and Derbyshire
|
Derby City Council Derbyshire County Council | Partially Responded | 1/2 |
| 24 Feb 2026 |
Patrick Griffin
2026-0114
· Chris Morris
A patient with advanced dementia became dehydrated and severely constipated at a care facility, despite recognized needs for dietary, fluid, and personal …
|
North West
Manchester South
|
Caring UK | All Responded | 1/1 |
| 23 Feb 2026 |
Susan Samson
2026-0112
· Rebecca Sutton
A patient was discharged home without consistently demonstrating safe stair use, and the current policy would allow this to recur, posing a …
|
North East
County Durham and Darlington
|
County Durham & Darlington NHS … | All Responded | 2/1 |
| 20 Feb 2026 |
Alan Crabtree
2026-0103
· Elizabeth Wheeler
Outdated methotrexate guidelines recommend a sub-therapeutic dose and create ambiguity in responsibilities between healthcare providers, risking fatal delays in toxicity management.
|
North West
Cheshire
|
Greater Manchester Medicines Management Group | All Responded | 2/1 |
| 20 Feb 2026 |
Sean Williams
2026-0105
· Ian Potter
A custody nurse failed to take vital signs before prescribing medication. Serco staff critically delayed first aid, didn't use emergency alerts, and …
|
London
Inner North London
|
Metropolitan Police Service Serco Prison Transport Services | All Responded | 2/2 |
| 19 Feb 2026 |
Jane Fenwick
2026-0104
· Hassan Shah
A patient with multiple choking risk factors was not referred for Speech and Language Therapy due to high intervention thresholds and long …
|
East Midlands
Northamptonshire
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 19 Feb 2026 |
Rajwinder Singh
2026-0100
· Bernard Richmond
HMP Wandsworth lacks mandatory ACCT refresher training for prison officers and equivalent training for agency healthcare staff, and offers no training in …
|
London
Inner West London
|
HMP Wandsworth NHS England Oxleas | No Identified Response | 0/3 |
| 19 Feb 2026 |
Jacqueline Joseph
2026-0102
· Bina Patel
The housing association property had two incorrectly installed battery-operated smoke alarms, posing a fire safety risk.
|
East of England
Bedfordshire and Luton
|
Luton Community Housing Ltd | All Responded | 1/1 |
| 17 Feb 2026 |
Benjamin Websdale
2026-0094
· Penelope Schofield
There's no national recording of police officer suicides during misconduct investigations, preventing identification of risk and support needs. Also, not all police …
|
South East
West Sussex, Brighton and Hove
|
National Police Chiefs Council | All Responded | 1/1 |
| 17 Feb 2026 |
Martin Ormond
2026-0098
· Alan Wilson
A GP made critical decisions without full information, and there was no effective process to ensure updated or additional reports reached the …
|
North West
Blackpool & Fylde
|
Broomwell Health Watch LYD Crescent Surgery | All Responded | 2/2 |
| 17 Feb 2026 |
Edward Hands
2026-0097
· Bina Patel
Confusion and differing policies between prison and healthcare staff regarding prisoners under the influence led to inadequate observation, failed recognition of clinical …
|
East of England
Bedfordshire and Luton
|
HMP Bedford Ministry of Justice Northamptonshire Healthcare Foundation Trust | All Responded | 3/3 |
| 16 Feb 2026 |
Geoffrey Gudgeon
2026-0095
· Andrew Cox
There is a significant capacity issue in Cornwall concerning the timely admission and treatment of stroke patients, leading to delays in accessing …
|
South West
Cornwall & the Isles of Scilly
|
Cornwall & Isles of Scilly … Royal Cornwall Hospitals NHS Trust | All Responded | 2/2 |
| Unknown |
Ellen Taylor
2026-0079
· Sarah Middleton
Hospital staff failed to recognise a patient's altered anatomy from previous gastric surgery during nasogastric tube insertion due to missing guidelines and …
|
North East
Northumberland
|
NHS England | All Responded | 1/1 |
| 13 Feb 2026 |
Edward Jones
2026-0096
· Oliver Longstaff
There is no nationally validated sepsis screening tool for Paediatric Emergency Departments, and the trust's own tool lacks consistent application between departments.
|
Yorkshire and the Humber
West Yorkshire East
|
National Institute for Health and … NHS England | Partially Responded | 1/2 |
| 12 Feb 2026 |
Rita Thomas and Christine Dale
2026-0093
· Robert Cohen
The junction design, coupled with the national speed limit on the A684, provides drivers with insufficient reaction time, increasing the risk of …
|
North West
Cumbria
|
National Highways | All Responded | 2/1 |
| 12 Feb 2026 |
Barry Harmer
2026-0203
· Crispin Butler
The initial Patient Safety Incident Investigation lacked robustness and did not appear to have been revisited in light of emerging family concerns; …
|
South East
Buckinghamshire
|
Oxford Health NHS Foundation Trust | Response Pending | 0/1 |
| 12 Feb 2026 |
James Fitzpatrick
2026-0087
· Rachael Griffin
A lack of national and local written guidance for patient handovers between staff and wards leads to incorrect or incomplete information being …
|
South West
Dorset
|
Dorset Healthcare University NHS Foundation … National Institute for Health and … General Medical Council (GMC) Nursing and Midwifery Council (NMC) | All Responded | 4/4 |
Urmila Patel
No Identified Response
Nursing failures included inadequate falls risk assessment, poor care-planning, and insufficient monitoring. Doctors also failed to decisively assess for intracranial bleeding or review warfarin …
Barts Health NHS Trust
Department of Health and …
Lesley Krommendijk
All Responded
Discharge assessment processes led to an unrealistic impression of the patient's mobility, potentially compromising patient safety.
Stockport NHS Foundation Trust
Raymond Moran
No Identified Response
The falls risk assessment was inaccurate, not updated, and documentation was incomplete.
HUTH
Emma Turner
Partially Responded
Poor information sharing and lack of system connectivity between agencies hindered care for a vulnerable adult. The GP safeguarding referral form was inadequate, causing …
Derby City Council
Derbyshire County Council
Patrick Griffin
All Responded
A patient with advanced dementia became dehydrated and severely constipated at a care facility, despite recognized needs for dietary, fluid, and personal care support.
Caring UK
Susan Samson
All Responded
A patient was discharged home without consistently demonstrating safe stair use, and the current policy would allow this to recur, posing a future fall …
County Durham & Darlington …
Alan Crabtree
All Responded
Outdated methotrexate guidelines recommend a sub-therapeutic dose and create ambiguity in responsibilities between healthcare providers, risking fatal delays in toxicity management.
Greater Manchester Medicines Management …
Sean Williams
All Responded
A custody nurse failed to take vital signs before prescribing medication. Serco staff critically delayed first aid, didn't use emergency alerts, and couldn't provide …
Metropolitan Police Service
Serco Prison Transport Services
Jane Fenwick
All Responded
A patient with multiple choking risk factors was not referred for Speech and Language Therapy due to high intervention thresholds and long waiting lists, …
Department of Health and …
NHS England
Rajwinder Singh
No Identified Response
HMP Wandsworth lacks mandatory ACCT refresher training for prison officers and equivalent training for agency healthcare staff, and offers no training in risk formulation.
HMP Wandsworth
NHS England
Oxleas
Jacqueline Joseph
All Responded
The housing association property had two incorrectly installed battery-operated smoke alarms, posing a fire safety risk.
Luton Community Housing Ltd
Benjamin Websdale
All Responded
There's no national recording of police officer suicides during misconduct investigations, preventing identification of risk and support needs. Also, not all police forces have …
National Police Chiefs Council
Martin Ormond
All Responded
A GP made critical decisions without full information, and there was no effective process to ensure updated or additional reports reached the GP before …
Broomwell Health Watch LYD
Crescent Surgery
Edward Hands
All Responded
Confusion and differing policies between prison and healthcare staff regarding prisoners under the influence led to inadequate observation, failed recognition of clinical deterioration, and …
HMP Bedford
Ministry of Justice
Northamptonshire Healthcare Foundation Trust
Geoffrey Gudgeon
All Responded
There is a significant capacity issue in Cornwall concerning the timely admission and treatment of stroke patients, leading to delays in accessing stroke units.
Cornwall & Isles of …
Royal Cornwall Hospitals NHS …
Ellen Taylor
All Responded
Hospital staff failed to recognise a patient's altered anatomy from previous gastric surgery during nasogastric tube insertion due to missing guidelines and routine consideration.
NHS England
Edward Jones
Partially Responded
There is no nationally validated sepsis screening tool for Paediatric Emergency Departments, and the trust's own tool lacks consistent application between departments.
National Institute for Health …
NHS England
Rita Thomas and Christine Dale
All Responded
The junction design, coupled with the national speed limit on the A684, provides drivers with insufficient reaction time, increasing the risk of serious collisions.
National Highways
Barry Harmer
Response Pending
The initial Patient Safety Incident Investigation lacked robustness and did not appear to have been revisited in light of emerging family concerns; proactive communication …
Oxford Health NHS Foundation …
James Fitzpatrick
All Responded
A lack of national and local written guidance for patient handovers between staff and wards leads to incorrect or incomplete information being transferred, risking …
Dorset Healthcare University NHS …
National Institute for Health …
General Medical Council (GMC)