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 8 of 317
Showing 20 at a time
| Date | Report | Region / area | Addressee(s) | Status | Responses |
|---|---|---|---|---|---|
| 6 Feb 2026 |
Paul Thompson
2026-0066
· Darren Stewart
HMP Norwich had inadequate arrangements for releasing prisoners needing mental health care, leading to failures in ensuring follow-up and timely information sharing …
|
East of England
Suffolk
|
HM Prison, Probation and reducing … | All Responded | 1/1 |
| 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 |
Linda Books
2026-0085
· Deborah Archer
The Trust showed a lack of staff training in escalating serious clinical incidents, no effective process for reviewing notes to identify issues, …
|
South West
Devon, Plymouth and Torbay
|
Torbay and South Devon NHS … | All Responded | 1/1 |
| 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 |
| 5 Feb 2026 |
Sam Dudley
2026-0060
· Anita Bhardwaj
Limited and ineffective signage on railway pedestrian gates, especially for earphone users, fails to provide adequate warnings at a critical "decision point."
|
North West
Sefton, St Helens and Knowsley
|
Level Crossings and Public Safety Level Crossing and Public Safety North West Route Director The Chief Coroner | Partially Responded | 1/4 |
| 5 Feb 2026 |
Angela Darlow
2026-0107
· Kate Robertson
Critically long ambulance delays, exacerbated by hospital handover issues, led to patients missing crucial time-sensitive treatments like thrombectomy for stroke.
|
Wales
North Wales (East and Central)
|
Cabinet Secretary for Health and … Department of Health and Social … | All Responded | 1/2 |
| 5 Feb 2026 |
Bruce Caulfield
2026-0062
· Chris Morris
Concerns include delays in medical reviews after family concerns, insufficient intentional rounding impacting vulnerable patient hydration, and inconsistent communication practices for fall …
|
North West
Manchester South
|
Manchester University NHS Foundation Trust | All Responded | 1/1 |
| 5 Feb 2026 |
Della Calvey
2026-0063
· Caroline Saunders
Unsafe practice of routinely downgrading NEWS scores for all COPD patients without knowing individual baseline saturations leads to inadequate clinical assessments.
|
Wales
Gwent
|
Anueron Bevan University Health Board Welsh Ambulance Service NHS Trust | All Responded | 2/2 |
| 5 Feb 2026 |
Kallum Reed
2026-0061
· Lydia Brown
Unacceptably long waits for ASD/ADHD services and mental health crisis team gate-keeping failures led to patients being denied crucial in-person assessments and …
|
London
West London
|
Department of Health and Social … West London NHS Trust | All Responded | 2/2 |
| 4 Feb 2026 |
Ryan Harding Prevention of future deaths report
2026-0054
· David Regan
Inadequate prison infrastructure allows illicit materials to enter. Scheduled welfare checks were also frequently delayed or missed due to staffing shortages.
|
Wales
South Wales Central
|
Governor of HM Prison Parc | All Responded | 1/1 |
| 4 Feb 2026 |
Lauren Moret-Dell
2026-0059
· Darren Stewart
Hospital staff lacked proficiency in timely TIA Clinic referrals. Additionally, out-of-hours stroke care lacked commissioned stroke consultant input, adversely impacting patient treatment …
|
East of England
Suffolk
|
Suffolk and North East Essex … West Suffolk NHS Foundation Trust | All Responded | 1/2 |
| 4 Feb 2026 |
Joan Read Prevention of future deaths report
2026-0055
· Rachel Knight
A single consultant lacking cross-cover for geriatric perioperative care creates a risk of urgent test results being missed during periods of absence.
|
Wales
South Wales Central
|
[REDACTED}, Chief Executive Cardiff & … | All Responded | 1/1 |
| 4 Feb 2026 |
Oliver Robinson
2026-0058
· Catherine McKenna
A consultant with inadequate expertise prescribed medicinal cannabis based on incomplete information, without consulting existing psychiatrists, obstructing the patient's appropriate psychiatric and …
|
North West
Manchester North
|
Curaleaf Clinic | All Responded | 1/1 |
| 4 Feb 2026 |
Georgia Scarff
2026-0057
· Darren Stewart
School staff unfamiliarity with the safeguarding system led to missed recordings. The lack of a single national safeguarding information management tool for …
|
East of England
Suffolk
|
Department for Education Minister for Women and Equalities Royal Hospital School | No Identified Response | 0/3 |
| 3 Feb 2026 |
Ellame Ford-Dunn Prevention of future deaths report
2026-0056
· Joanne Andrews
Insufficient Tier 4 Paediatric Mental Health beds lead to long waits, resulting in children with mental health needs being inappropriately held on …
|
South East
West Sussex, Brighton and Hove
|
NHS England & NHS Improvement | All Responded | 1/1 |
| 3 Feb 2026 |
Lyn Maher
2026-0053
· Rachel Knight
Community pharmacists in Wales faced confusion regarding clinical checks and patient confidentiality, and had limited access to crucial drug history via the …
|
Wales
South Wales Central
|
Digital Health and Care, Wales General Pharmaceutical Council Health and Social Care for … [REDACTED] Chief Executive Officer (CEO), … | Partially Responded | 1/4 |
| 3 Feb 2026 |
Nathan Cyster
2026-0051
· Daniel Howe
Hazardous right-turn manoeuvres, absent "left turn only" signage, ineffective road markings, and ambiguous legal guidance for crossing double white lines collectively create …
|
West Midlands
Staffordshire and Stoke-on-Trent
|
Department of Transport Moss Farm National Highways | All Responded | 3/3 |
| 2 Feb 2026 |
Heather Parkhill
2026-0050
· John Gittens
Persistent ambulance delays and resource unavailability continue to put lives at risk, despite ongoing multi-agency efforts to address these long-standing issues.
|
Wales
North Wales (East and Central)
|
Welsh Ambulance Services University NHS … | All Responded | 2/1 |
| 2 Feb 2026 |
Avery Hall
2026-0048
· David Place
A GP failed to provide specific advice on Candesartan risks during pregnancy, and the medication remained on repeat prescription, approved without review …
|
North East
Sunderland
|
Riverview Surgery Royal College of General Practitioners | All Responded | 2/2 |
| 2 Feb 2026 |
Scott Taylor
2026-0092
· Sonia Hayes
Ambulance service triage for Acute Behavioural Disturbance suffered from incorrect call categorisation and confusing, inconsistent training. Police training for Special Constables on …
|
East of England
Essex
|
Association of Ambulance Chief Executives East of England Ambulance NHS … Essex Police | All Responded | 3/3 |
Paul Thompson
All Responded
HMP Norwich had inadequate arrangements for releasing prisoners needing mental health care, leading to failures in ensuring follow-up and timely information sharing with Probation …
HM Prison, Probation and …
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 …
Linda Books
All Responded
The Trust showed a lack of staff training in escalating serious clinical incidents, no effective process for reviewing notes to identify issues, and confusion …
Torbay and South Devon …
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, …
Sam Dudley
Partially Responded
Limited and ineffective signage on railway pedestrian gates, especially for earphone users, fails to provide adequate warnings at a critical "decision point."
Level Crossings and Public …
Level Crossing and Public …
North West Route Director
Angela Darlow
All Responded
Critically long ambulance delays, exacerbated by hospital handover issues, led to patients missing crucial time-sensitive treatments like thrombectomy for stroke.
Cabinet Secretary for Health …
Department of Health and …
Bruce Caulfield
All Responded
Concerns include delays in medical reviews after family concerns, insufficient intentional rounding impacting vulnerable patient hydration, and inconsistent communication practices for fall prevention across …
Manchester University NHS Foundation …
Della Calvey
All Responded
Unsafe practice of routinely downgrading NEWS scores for all COPD patients without knowing individual baseline saturations leads to inadequate clinical assessments.
Anueron Bevan University Health …
Welsh Ambulance Service NHS …
Kallum Reed
All Responded
Unacceptably long waits for ASD/ADHD services and mental health crisis team gate-keeping failures led to patients being denied crucial in-person assessments and ongoing close …
Department of Health and …
West London NHS Trust
Ryan Harding Prevention of future deaths report
All Responded
Inadequate prison infrastructure allows illicit materials to enter. Scheduled welfare checks were also frequently delayed or missed due to staffing shortages.
Governor of HM Prison …
Lauren Moret-Dell
All Responded
Hospital staff lacked proficiency in timely TIA Clinic referrals. Additionally, out-of-hours stroke care lacked commissioned stroke consultant input, adversely impacting patient treatment outcomes.
Suffolk and North East …
West Suffolk NHS Foundation …
Joan Read Prevention of future deaths report
All Responded
A single consultant lacking cross-cover for geriatric perioperative care creates a risk of urgent test results being missed during periods of absence.
[REDACTED}, Chief Executive Cardiff …
Oliver Robinson
All Responded
A consultant with inadequate expertise prescribed medicinal cannabis based on incomplete information, without consulting existing psychiatrists, obstructing the patient's appropriate psychiatric and addiction care.
Curaleaf Clinic
Georgia Scarff
No Identified Response
School staff unfamiliarity with the safeguarding system led to missed recordings. The lack of a single national safeguarding information management tool for schools creates …
Department for Education
Minister for Women and …
Royal Hospital School
Ellame Ford-Dunn Prevention of future deaths report
All Responded
Insufficient Tier 4 Paediatric Mental Health beds lead to long waits, resulting in children with mental health needs being inappropriately held on acute paediatric …
NHS England & NHS …
Lyn Maher
Partially Responded
Community pharmacists in Wales faced confusion regarding clinical checks and patient confidentiality, and had limited access to crucial drug history via the Welsh Clinical …
Digital Health and Care, …
General Pharmaceutical Council
Health and Social Care …
Nathan Cyster
All Responded
Hazardous right-turn manoeuvres, absent "left turn only" signage, ineffective road markings, and ambiguous legal guidance for crossing double white lines collectively create a dangerous …
Department of Transport
Moss Farm
National Highways
Heather Parkhill
All Responded
Persistent ambulance delays and resource unavailability continue to put lives at risk, despite ongoing multi-agency efforts to address these long-standing issues.
Welsh Ambulance Services University …
Avery Hall
All Responded
A GP failed to provide specific advice on Candesartan risks during pregnancy, and the medication remained on repeat prescription, approved without review or system …
Riverview Surgery
Royal College of General …
Scott Taylor
All Responded
Ambulance service triage for Acute Behavioural Disturbance suffered from incorrect call categorisation and confusing, inconsistent training. Police training for Special Constables on ABD recognition …
Association of Ambulance Chief …
East of England Ambulance …
Essex Police