UK Inquiry Tracker

#	Category	Trend	Reports	Areas
1	Hospital Death (Clinical Procedures and medical management) related deaths 70 reports in the last 6 months across 35 coroner areas. Report volume is below the historical average.	Cooling	70	35
2	Suicide 37 reports in the last 6 months across 23 coroner areas.	Stable	37	23
3	Other related deaths 25 reports in the last 6 months across 17 coroner areas.	Stable	25	17
4	Alcohol, drug and medication related deaths 24 reports in the last 6 months across 16 coroner areas.	Stable	24	16
5	Child Death 23 reports in the last 6 months across 16 coroner areas. Report volume is above the historical average.	Rising	23	16
6	State Custody related deaths 19 reports in the last 6 months across 12 coroner areas. Report volume is above the historical average.	Rising	19	12
7	Mental Health related deaths 17 reports in the last 6 months across 14 coroner areas. Report volume is below the historical average.	Cooling	17	14
8	Community health care and emergency services related deaths 16 reports in the last 6 months across 12 coroner areas. Report volume is below the historical average.	Cooling	16	12
9	Road (Highways Safety) related deaths 12 reports in the last 6 months across 10 coroner areas. Report volume is below the historical average.	Cooling	12	10
10	Emergency services related deaths 11 reports in the last 6 months across 10 coroner areas.	Stable	11	10
11	Wales prevention of future deaths reports 8 reports in the last 6 months across 3 coroner areas.	Stable	8	3
12	Care Home Health related deaths 5 reports in the last 6 months across 5 coroner areas. Report volume is below the historical average.	Cooling	5	5
13	Railway related deaths 4 reports in the last 6 months across 3 coroner areas.	Stable	4	3
14	Police related deaths 2 reports in the last 6 months across 2 coroner areas. Report volume is below the historical average.	Cooling	2	2

#	Category	Trend	Reports	Areas
1	Hospital Death (Clinical Procedures and medical management) related deaths 183 reports in the last 12 months across 49 coroner areas.	Stable	183	49
2	Suicide 100 reports in the last 12 months across 46 coroner areas. Report volume has more than doubled compared to the historical average.	Surging	100	46
3	Alcohol, drug and medication related deaths 65 reports in the last 12 months across 34 coroner areas. Report volume has more than doubled compared to the historical average.	Surging	65	34
4	Child Death 49 reports in the last 12 months across 28 coroner areas. Report volume is above the historical average.	Rising	49	28
5	Other related deaths 45 reports in the last 12 months across 29 coroner areas. Report volume is below the historical average.	Cooling	45	29
6	Mental Health related deaths 42 reports in the last 12 months across 26 coroner areas.	Stable	42	26
7	Community health care and emergency services related deaths 40 reports in the last 12 months across 23 coroner areas.	Stable	40	23
8	State Custody related deaths 40 reports in the last 12 months across 23 coroner areas. Report volume is above the historical average.	Rising	40	23
9	Road (Highways Safety) related deaths 32 reports in the last 12 months across 22 coroner areas.	Stable	32	22
10	Emergency services related deaths 30 reports in the last 12 months across 25 coroner areas. Report volume has more than doubled compared to the historical average.	Surging	30	25
11	Care Home Health related deaths 29 reports in the last 12 months across 18 coroner areas.	Stable	29	18
12	Wales prevention of future deaths reports 25 reports in the last 12 months across 5 coroner areas. Report volume has more than doubled compared to the historical average.	Surging	25	5
13	Police related deaths 12 reports in the last 12 months across 10 coroner areas.	Stable	12	10
14	Railway related deaths 8 reports in the last 12 months across 7 coroner areas.	Stable	8	7
15	Product related deaths 4 reports in the last 12 months across 4 coroner areas. Report volume is below the historical average.	Cooling	4	4
16	Accident at Work and Health and Safety related deaths 3 reports in the last 12 months across 3 coroner areas. Report volume is below the historical average.	Cooling	3	3

#	Category	Reports	Areas
1	Hospital Death (Clinical Procedures and medical management) related deaths 2,471 reports across all time in 72 coroner areas.	2,471	72
2	Suicide 829 reports across all time in 72 coroner areas.	829	72
3	Other related deaths 772 reports across all time in 72 coroner areas.	772	72
4	Mental Health related deaths 617 reports across all time in 69 coroner areas.	617	69
5	Community health care and emergency services related deaths 601 reports across all time in 69 coroner areas.	601	69
6	Alcohol, drug and medication related deaths 540 reports across all time in 67 coroner areas.	540	67
7	Road (Highways Safety) related deaths 497 reports across all time in 68 coroner areas.	497	68
8	Child Death 440 reports across all time in 65 coroner areas.	440	65
9	Care Home Health related deaths 403 reports across all time in 66 coroner areas.	403	66
10	State Custody related deaths 355 reports across all time in 57 coroner areas.	355	57
11	Emergency services related deaths 253 reports across all time in 59 coroner areas.	253	59
12	Wales prevention of future deaths reports 186 reports across all time in 7 coroner areas.	186	7
13	Police related deaths 147 reports across all time in 51 coroner areas.	147	51
14	Product related deaths 129 reports across all time in 54 coroner areas.	129	54
15	Railway related deaths 97 reports across all time in 39 coroner areas.	97	39
16	Accident at Work and Health and Safety related deaths 87 reports across all time in 44 coroner areas.	87	44
17	Service Personnel related deaths 32 reports across all time in 18 coroner areas.	32	18

#	Theme	Trend	PFD reports
1	Mental Health Crisis Referral Delays Mental Health	Surging	17
2	Prison Overcrowding & Staff Vacancies Prison & Custody Safety	Surging	16
3	Clinical negligence harms learning Care Quality & Organisational Culture	Surging	12
4	Patient safety governance Care Quality & Organisational Culture	Surging	12
5	Prison healthcare best practice Prison & Custody Safety	Surging	12
6	Poor health and social care integration Healthcare & Patient Safety	Surging	11
7	Poor prisoner suicide risk assessment Mental Health	Surging	10
8	Design flaws enabling suicide Mental Health	Surging	9
9	Conflicting mental health care plans Mental Health	Surging	8
10	Emergency responder equipment training Emergency Services & Preparedness	Surging	7
11	Ligature points Mental Health	Surging	7
12	Falls prevention plans Social Care	Surging	6
13	Prison ACCT process flaws Mental Health	Surging	5
14	Poor mental health suicide risk assessment Mental Health	Rising	12
15	Care home safety and capacity Social Care	Rising	9
16	Care home staffing levels Social Care	Rising	9
17	Inappropriate Emergency Call Transfers Emergency Services & Preparedness	Rising	5
18	Ambulance Handover Delays Emergency Services & Preparedness	Stable	11
19	Unaddressed Road Safety Risks Transport Safety	Stable	10
20	Urgent care pathways Emergency Services & Preparedness	Stable	8
21	Emergency contingency plans Emergency Services & Preparedness	Stable	7
22	Fragmented NHS record access and information sharing Healthcare & Patient Safety	Stable	6
23	Pharmacist missed drug contraindications Healthcare & Patient Safety	Stable	4
24	Care home alert systems Social Care	Stable	3
25	GP oversight of specialist care Healthcare & Patient Safety	Stable	3
26	Staff training and development Workforce & Staffing	Cooling	17
27	Care and discharge planning Care Quality & Organisational Culture	Cooling	13
28	Delayed Recognition of Deterioration Healthcare & Patient Safety	Cooling	9
29	Chronic healthcare staff shortages Workforce & Staffing	Cooling	7
30	Inaccurate and inaccessible patient records Data & Technology	Cooling	6
31	No person-centred care Care Quality & Organisational Culture	Cooling	5
32	Hazardous road design Transport Safety	Cooling	4
33	Unregulated recreation safety Building & Fire Safety	Cooling	4
34	Public Infrastructure Physical Hazards Building & Fire Safety	Cooling	4
35	Mental health access for alcohol addiction Mental Health	Cooling	3
36	Outdated Operational Guidance Data & Technology	Cooling	3
37	Care plan failures Care Quality & Organisational Culture	Cooling	3
38	Incomplete GP Patient Data Transfer Healthcare & Patient Safety	Cooling	3
39	Inconsistent Healthcare Data Infrastructure Data & Technology	Cooling	3
40	Police investigation management Police Conduct & Accountability	Cooling	3
41	Care risk assessment failures Care Quality & Organisational Culture	Cooling	2
42	Missed and inaccurate patient observations Healthcare & Patient Safety	Cooling	2
43	Inadequate Pre-Operative Risk Assessment Healthcare & Patient Safety	Cooling	2
44	Inadequate Road Safety Barriers Transport Safety	Cooling	2
45	MAR chart errors Healthcare & Patient Safety	Cooling	2
46	Staff rota communication Workforce & Staffing	Cooling	2
47	No open learning culture Care Quality & Organisational Culture	Cooling	1
48	Unsafe medication management Healthcare & Patient Safety	Cooling	1
49	Poor prevention and early intervention Healthcare & Patient Safety	Cooling	1

#	Theme	Trend	PFD reports
1	Urgent care pathways Emergency Services & Preparedness	Surging	31
2	Patient safety governance Care Quality & Organisational Culture	Surging	27
3	Prison Overcrowding & Staff Vacancies Prison & Custody Safety	Surging	26
4	Ligature points Mental Health	Surging	19
5	Prison healthcare best practice Prison & Custody Safety	Surging	17
6	Design flaws enabling suicide Mental Health	Surging	15
7	Emergency responder equipment training Emergency Services & Preparedness	Surging	15
8	Poor prisoner suicide risk assessment Mental Health	Surging	15
9	Conflicting mental health care plans Mental Health	Surging	11
10	Prison ACCT process flaws Mental Health	Surging	10
11	Mental Health Crisis Referral Delays Mental Health	Rising	23
12	Poor mental health suicide risk assessment Mental Health	Rising	23
13	Clinical negligence harms learning Care Quality & Organisational Culture	Rising	18
14	Care home safety and capacity Social Care	Rising	18
15	Care home staffing levels Social Care	Rising	17
16	Incomplete GP Patient Data Transfer Healthcare & Patient Safety	Rising	16
17	Poor health and social care integration Healthcare & Patient Safety	Rising	15
18	Care risk assessment failures Care Quality & Organisational Culture	Rising	14
19	Missed and inaccurate patient observations Healthcare & Patient Safety	Rising	14
20	Police investigation management Police Conduct & Accountability	Rising	11
21	Inappropriate Emergency Call Transfers Emergency Services & Preparedness	Rising	10
22	Care home alert systems Social Care	Rising	9
23	Staff training and development Workforce & Staffing	Stable	87
24	Inaccurate and inaccessible patient records Data & Technology	Stable	42
25	Care and discharge planning Care Quality & Organisational Culture	Stable	35
26	Delayed Recognition of Deterioration Healthcare & Patient Safety	Stable	32
27	Ambulance Handover Delays Emergency Services & Preparedness	Stable	24
28	Mental health access for alcohol addiction Mental Health	Stable	22
29	Chronic healthcare staff shortages Workforce & Staffing	Stable	20
30	No person-centred care Care Quality & Organisational Culture	Stable	17
31	Emergency contingency plans Emergency Services & Preparedness	Stable	13
32	Fragmented NHS record access and information sharing Healthcare & Patient Safety	Stable	13
33	Inadequate Pre-Operative Risk Assessment Healthcare & Patient Safety	Stable	13
34	Care plan failures Care Quality & Organisational Culture	Stable	11
35	MAR chart errors Healthcare & Patient Safety	Stable	9
36	Falls prevention plans Social Care	Stable	9
37	Pharmacist missed drug contraindications Healthcare & Patient Safety	Stable	8
38	GP oversight of specialist care Healthcare & Patient Safety	Stable	8
39	Staff rota communication Workforce & Staffing	Stable	7
40	Unaddressed Road Safety Risks Transport Safety	Cooling	17
41	No open learning culture Care Quality & Organisational Culture	Cooling	15
42	Public Infrastructure Physical Hazards Building & Fire Safety	Cooling	12
43	Hazardous road design Transport Safety	Cooling	11
44	Unregulated recreation safety Building & Fire Safety	Cooling	9
45	Outdated Operational Guidance Data & Technology	Cooling	6
46	Emergency family notification Emergency Services & Preparedness	Cooling	6
47	Unsafe medication management Healthcare & Patient Safety	Cooling	5
48	Inconsistent Healthcare Data Infrastructure Data & Technology	Cooling	5
49	Poor prevention and early intervention Healthcare & Patient Safety	Cooling	5
50	Inadequate Road Safety Barriers Transport Safety	Cooling	4

#	Theme	PFD reports
1	Staff training and development Workforce & Staffing	1,030
2	Inaccurate and inaccessible patient records Data & Technology	648
3	Care and discharge planning Care Quality & Organisational Culture	519
4	Delayed Recognition of Deterioration Healthcare & Patient Safety	410
5	Ambulance Handover Delays Emergency Services & Preparedness	296
6	Unaddressed Road Safety Risks Transport Safety	296
7	Chronic healthcare staff shortages Workforce & Staffing	275
8	Mental health access for alcohol addiction Mental Health	274
9	No open learning culture Care Quality & Organisational Culture	267
10	Mental Health Crisis Referral Delays Mental Health	253
11	Poor mental health suicide risk assessment Mental Health	243
12	Hazardous road design Transport Safety	240
13	No person-centred care Care Quality & Organisational Culture	237
14	Urgent care pathways Emergency Services & Preparedness	230
15	Outdated Operational Guidance Data & Technology	220
16	Unregulated recreation safety Building & Fire Safety	209
17	Public Infrastructure Physical Hazards Building & Fire Safety	200
18	Clinical negligence harms learning Care Quality & Organisational Culture	193
19	Care home safety and capacity Social Care	163
20	Care home staffing levels Social Care	161
21	Poor health and social care integration Healthcare & Patient Safety	160
22	Emergency contingency plans Emergency Services & Preparedness	159
23	Fragmented NHS record access and information sharing Healthcare & Patient Safety	154
24	Care risk assessment failures Care Quality & Organisational Culture	151
25	Missed and inaccurate patient observations Healthcare & Patient Safety	149
26	Inadequate Pre-Operative Risk Assessment Healthcare & Patient Safety	146
27	Care plan failures Care Quality & Organisational Culture	146
28	Patient safety governance Care Quality & Organisational Culture	145
29	Incomplete GP Patient Data Transfer Healthcare & Patient Safety	143
30	Prison Overcrowding & Staff Vacancies Prison & Custody Safety	140
31	Inadequate Road Safety Barriers Transport Safety	119
32	Unsafe medication management Healthcare & Patient Safety	118
33	Inconsistent Healthcare Data Infrastructure Data & Technology	117
34	Police investigation management Police Conduct & Accountability	116
35	Design flaws enabling suicide Mental Health	116
36	MAR chart errors Healthcare & Patient Safety	114
37	Emergency family notification Emergency Services & Preparedness	113
38	Emergency responder equipment training Emergency Services & Preparedness	113
39	Pharmacist missed drug contraindications Healthcare & Patient Safety	108
40	Prison healthcare best practice Prison & Custody Safety	107
41	Ligature points Mental Health	104
42	Falls prevention plans Social Care	101
43	Poor prisoner suicide risk assessment Mental Health	99
44	Conflicting mental health care plans Mental Health	97
45	Staff rota communication Workforce & Staffing	94
46	Care home alert systems Social Care	92
47	Poor prevention and early intervention Healthcare & Patient Safety	92
48	GP oversight of specialist care Healthcare & Patient Safety	91
49	Inappropriate Emergency Call Transfers Emergency Services & Preparedness	89
50	Prison ACCT process flaws Mental Health	86

PFD Themes