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 7 of 317
Showing 20 at a time
| Date | Report | Region / area | Addressee(s) | Status | Responses |
|---|---|---|---|---|---|
| 11 Feb 2026 |
Chloe Ulett
2026-0086
· Emma Brown
There is a lack of routine ammonia testing for acutely confused adults, and current RCEM guidelines for metabolic disorders are not well-embedded …
|
West Midlands
Birmingham and Solihull
|
Faculty of Intensive Care Medicine Royal College of Emergency Medicine … Royal College of Midwives Royal College of Obstetricians and … | All Responded | 5/4 |
| 10 Feb 2026 |
Samuel Dickinson
2026-0082
· Michael Pemberton
Gaps in firearms legislation mean licence holders are not required to self-report medical conditions, and GPs are not obligated to record licences …
|
North West
Manchester West
|
Department of Health and Social … Home Office | All Responded | 2/2 |
| 10 Feb 2026 |
Liam Sutton
2026-0090
· Catherine Wood
Persistent delays in discharging medically fit patients due to inadequate community care provision block acute beds, leading to dangerous overcrowding in emergency …
|
South East
Kent and Medway
|
Department of Health and Social … Kent and Medway Integrated Care … Kent County Council Medway Council | All Responded | 2/4 |
| 10 Feb 2026 |
Barbara Wingate
2026-0088
· Catherine Wood
Persistent issues with patient discharge delays due to inadequate community care provisions cause emergency department overcrowding and restrict timely access to acute …
|
South East
Kent and Medway
|
Department of Health and Social … Kent and Medway Integrated Care … Kent County Council Medway Council | All Responded | 2/4 |
| 10 Feb 2026 |
David Thompson
2026-0080
· Alison Longhorn
Police widely use the term 'suicidal ideation' which is not understood by the public or consistently by officers, risking critical information being …
|
South West
Devon, Plymouth & Torbay
|
Devon & Cornwall Police | All Responded | 1/1 |
| 9 Feb 2026 |
Josh Tarrant (2)
2026-0076
· Scott Matthewson
Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged …
|
South East
Mid Kent & Medway
|
Probation and Reducing Reoffending, Ministry … Prisons, Probation and Reducing Reoffending | No Identified Response | 0/2 |
| 9 Feb 2026 |
Josh Tarrant (1)
2026-0075
· Scott Matthewson
Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged …
|
South East
Mid Kent & Medway
|
NHS England | All Responded | 1/1 |
| 9 Feb 2026 |
Helen Patching, Rachael Patching and Corey Longdon
2026-0081
· Rachel Knight
Inadequate signage fails to address significant falling risks in 'Waterfall Country', and poor mobile phone signal hinders emergency services' response times.
|
Wales
South Wales Central
|
Bannau Brycheiniog National Park Natural Resources Wales Neath Port Talbot County Borough … Powys County Council | No Identified Response | 0/5 |
| 9 Feb 2026 |
Gareth Chumber-Kelly
2026-0073
· Jonathan Stevens
Inefficient prison reception processes lead to lost critical prisoner information, and suicide/self-harm training for staff was suspended despite high rates of suicidal …
|
London
North London
|
HMP Pentonville HMPPS Ministry for Justice Serco | Partially Responded | 2/4 |
| 9 Feb 2026 |
Janet Tripp
2026-0091
· Guy Davies
Insufficient evidence shows that previously identified hospital failings have been addressed, indicating ongoing risks to patient safety.
|
South West
Cornwall & the Isles of Scilly
|
Royal Cornwall Hospital | All Responded | 1/1 |
| 9 Feb 2026 |
Brody O’Brien
2026-0084
· Emma Mather
An unsecured ligature point was accessible, and emergency services faced difficult, treacherous access to the location, hindering timely intervention.
|
North West
Lancashire and Blackburn with Darwen
|
Health and Safety Executive Rossendale Borough Council | All Responded | 2/2 |
| 9 Feb 2026 |
Josh Tarrant (3)
2026-0077
· Scott Matthewson
Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged …
|
South East
Mid Kent & Medway
|
HMP Elmley | All Responded | 1/1 |
| 8 Feb 2026 |
John Franklin
2026-0110
· Sarah Murphy
A high-risk falls patient was discharged home before a careline/lifeline pendant was provided, delaying assistance when the patient subsequently fell.
|
West Midlands
Worcestershire
|
Worcestershire County Council | All Responded | 1/1 |
| 8 Feb 2026 |
Elise Sebastian
2026-0078
· Sonia Hayes
Mental health ward staff lacked neurodiversity training and were inexperienced, leading to insufficient staffing, missed patient observations, and incorrect medication charting.
|
East of England
Essex
|
Essex University Partnership Trust | All Responded | 1/1 |
| 8 Feb 2026 |
Luke Abrahams
2026-0201
· Sophie Lomas
There are difficulties in diagnosing necrotising fasciitis, and the NHS website does not make it clear that the condition can present as …
|
East Midlands
Northamptonshire
|
NHS England | All Responded | 1/1 |
| 7 Feb 2026 |
Janet Springall
2026-0074
· Alan Anthony
Hospital emergency departments face significant pressures, causing unwell patients to remain in ambulances and delaying critical treatment, which reduces survival chances.
|
North West
Blackpool & Fylde
|
Care Quality Commission Department of Health and Social … | No Identified Response | 0/2 |
| 7 Feb 2026 |
Bonita Cleary
2026-0067
· Alan Wilson
A lack of awareness among care staff regarding when CPR should be attempted risks potentially reversible deaths in vulnerable residents.
|
North West
Blackpool & Fylde
|
Care Quality Commission Curo Care Delahey’s | No Identified Response | 0/2 |
| 6 Feb 2026 |
Micheala Finch
2026-0064
· Timothy Brennand
Hospital discharge decisions failed to adequately assess a patient's significant mental health deterioration and suicidal ideation, attributing issues solely to alcohol misuse …
|
North West
Manchester West
|
Greater Manchester Integrated Care Partnership Greater Manchester Mental Health | All Responded | 2/2 |
| 6 Feb 2026 |
Mansoor Zaman
2026-0072
· Graeme Irvine
Nursing staff failed to instigate MHA authorisations, adequately document care, reappraise risk after violent behaviour and absconding, and promptly report a missing …
|
London
East London
|
Department of Health and Social … East London Foundation NHS Trust | All Responded | 3/2 |
| 6 Feb 2026 |
Emmett Morrison
2026-0071
· David Reid
HMP Long Lartin suffered from a continued influx of illicit drugs. There were also systemic failures in the ACCT process, with no …
|
West Midlands
Worcestershire
|
Prison, Probation and Reducing Offending Probation and Reducing Offending, Ministry … | All Responded | 1/2 |
Chloe Ulett
All Responded
There is a lack of routine ammonia testing for acutely confused adults, and current RCEM guidelines for metabolic disorders are not well-embedded or sufficiently …
Faculty of Intensive Care …
Royal College of Emergency …
Royal College of Midwives
Samuel Dickinson
All Responded
Gaps in firearms legislation mean licence holders are not required to self-report medical conditions, and GPs are not obligated to record licences or report …
Department of Health and …
Home Office
Liam Sutton
All Responded
Persistent delays in discharging medically fit patients due to inadequate community care provision block acute beds, leading to dangerous overcrowding in emergency departments and …
Department of Health and …
Kent and Medway Integrated …
Kent County Council
Barbara Wingate
All Responded
Persistent issues with patient discharge delays due to inadequate community care provisions cause emergency department overcrowding and restrict timely access to acute care.
Department of Health and …
Kent and Medway Integrated …
Kent County Council
David Thompson
All Responded
Police widely use the term 'suicidal ideation' which is not understood by the public or consistently by officers, risking critical information being missed in …
Devon & Cornwall Police
Josh Tarrant (2)
No Identified Response
Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.
Probation and Reducing Reoffending, …
Prisons, Probation and Reducing …
Josh Tarrant (1)
All Responded
Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.
NHS England
Helen Patching, Rachael Patching and Corey Longdon
No Identified Response
Inadequate signage fails to address significant falling risks in 'Waterfall Country', and poor mobile phone signal hinders emergency services' response times.
Bannau Brycheiniog National Park
Natural Resources Wales
Neath Port Talbot County …
Gareth Chumber-Kelly
Partially Responded
Inefficient prison reception processes lead to lost critical prisoner information, and suicide/self-harm training for staff was suspended despite high rates of suicidal ideation and …
HMP Pentonville
HMPPS
Ministry for Justice
Janet Tripp
All Responded
Insufficient evidence shows that previously identified hospital failings have been addressed, indicating ongoing risks to patient safety.
Royal Cornwall Hospital
Brody O’Brien
All Responded
An unsecured ligature point was accessible, and emergency services faced difficult, treacherous access to the location, hindering timely intervention.
Health and Safety Executive
Rossendale Borough Council
Josh Tarrant (3)
All Responded
Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.
HMP Elmley
John Franklin
All Responded
A high-risk falls patient was discharged home before a careline/lifeline pendant was provided, delaying assistance when the patient subsequently fell.
Worcestershire County Council
Elise Sebastian
All Responded
Mental health ward staff lacked neurodiversity training and were inexperienced, leading to insufficient staffing, missed patient observations, and incorrect medication charting.
Essex University Partnership Trust
Luke Abrahams
All Responded
There are difficulties in diagnosing necrotising fasciitis, and the NHS website does not make it clear that the condition can present as intense/disproportionate pain …
NHS England
Janet Springall
No Identified Response
Hospital emergency departments face significant pressures, causing unwell patients to remain in ambulances and delaying critical treatment, which reduces survival chances.
Care Quality Commission
Department of Health and …
Bonita Cleary
No Identified Response
A lack of awareness among care staff regarding when CPR should be attempted risks potentially reversible deaths in vulnerable residents.
Care Quality Commission
Curo Care Delahey’s
Micheala Finch
All Responded
Hospital discharge decisions failed to adequately assess a patient's significant mental health deterioration and suicidal ideation, attributing issues solely to alcohol misuse and not …
Greater Manchester Integrated Care …
Greater Manchester Mental Health
Mansoor Zaman
All Responded
Nursing staff failed to instigate MHA authorisations, adequately document care, reappraise risk after violent behaviour and absconding, and promptly report a missing patient to …
Department of Health and …
East London Foundation NHS …
Emmett Morrison
All Responded
HMP Long Lartin suffered from a continued influx of illicit drugs. There were also systemic failures in the ACCT process, with no support actions …
Prison, Probation and Reducing …
Probation and Reducing Offending, …