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Prevention of Future Deaths
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Total: 4,638 Responded: 4,638 No identified response (past 2 years): 0 Pending: 0
How statuses are calculated — 56-day deadline, Judiciary.UK data
Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date. We rely on Judiciary.UK for response data, so if a response has been provided but not yet published there, it may show incorrectly here. "No identified response", "Pending", and "Historic" only count reports where no response at all has been identified as published on Judiciary.UK. If at least one response has been published for a report, it counts as "Responded" — even if not every listed addressee has a separate published response. This is because addressee data from Judiciary.UK can be unreliable: address fragments, job titles, and redacted names are sometimes parsed as separate addressees, and a single response PDF may cover multiple parties. "Historic with no identified response" means we have not been able to identify a published response, but the report is more than two years old. We do not mark these as overdue or pending because older reports may well have received a response that was simply never made public. This is a neutral status indicating absence of an identified published record, not confirmed non-compliance.
22 reports include a non-response confirmed by the Chief Coroner. Show only confirmed
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4,638 reports · Page 74 of 93
Date Deceased Addressee(s) Status Responses
31 Oct 2016 Frederick Squires
A lack of clear clinical guidance on when to reintroduce Warfarin after a head injury risks either premature …
 N.I.C.E All Responded 1/1
28 Oct 2016 Alfred Grimshaw
A critical hip fracture was missed during initial assessment and an X-ray report. Pre-discharge physiotherapy and occupational therapy …
 East Lancashire Healthcare NHS Trust All Responded 1/1
27 Oct 2016 Samuel Carroll
Police and ambulance services failed to obtain consent to inform family or friends about a patient's suicidal ideation …
 North Yorkshire Police Yorkshire Ambulance Service NHS Trust All Responded 2/2
26 Oct 2016 Alfie Rose
Poor inter-hospital communication and ineffective information sharing systems led to missed opportunities for patient transfer and treatment. Clinicians …
 Dudley Group of Hospitals NHS … University Hospitals Birmingham NHS Trust All Responded 2/2
25 Oct 2016 Matthew Llewellyn-Jones
Ward security remains compromised by breached "locked doors" and predictable patient observations, deviating from best practice. The note-recording …
 Devon Partnership Trust All Responded 1/1
25 Oct 2016 Kevin Hefferman
Persistent standing water and water flow across a specific carriageway section contributed to numerous past collisions, posing an …
 Highways England All Responded 1/1
25 Oct 2016 Ivy Atkin
A regulatory loophole allows individuals with criminal convictions to become "Nominated Individuals" for care homes without independent suitability …
 Care Quality Commission Department of Health and Social … All Responded 2/2
25 Oct 2016 Richard Walsh
Systemic failures and inadequate communication processes between police, courts, healthcare, and prison services led to crucial mental health …
 Department of Health and Social … Hampshire County Council Ministry of Justice All Responded 4/3
25 Oct 2016 Jane Reason
There is a critical shortage of public access defibrillators in colleges and schools, and a need for increased …
 Department of Health and Social … Resuscitation Council NHS England Department for Education All Responded 4/4
24 Oct 2016 Joan Green
The junction design is "challenging" and dangerous, evidenced by a history of fatal collisions and observed "near misses." …
 Lincolnshire County Council All Responded 1/1
24 Oct 2016 Margaret Dempsie
Hospital discharge letters contained significant inaccuracies and omissions, often completed by junior doctors who hadn't seen the patient, …
 NHS England University Hospitals of Leicester NHS … All Responded 3/2
20 Oct 2016 Colin Garth
The report text does not detail specific concerns.
 Bolton NHS Trust All Responded 1/1
20 Oct 2016 Victoria Halliday
A lack of local female psychiatric intensive care beds, ineffective community psychiatric nursing, and inadequate community support for …
 Leicestershire Partnership NHS Trust All Responded 3/1
19 Oct 2016 Benjamin Orrill
The lack of a regulatory body for advanced nurse practitioners, leading to inconsistent appraisal, revalidation, and potential unsupervised …
 NHS England Nursing and Midwifery Council All Responded 2/2
18 Oct 2016 Isaac Brocklehurst
There is a concern about the safety of pedestrian gaps in a low perimeter wall within a communal …
 Incommunities All Responded 1/1
18 Oct 2016 Captain James Bedforth
Inadequate DVT scanning guidelines and poor safety-netting led to missed diagnosis. Delayed assessment in ED, issues with anticoagulation …
 Barnsley Hospital NHS Trust Department of Health and Social … Partially Responded 1/2
14 Oct 2016 Peter Keep
The hospital lacked a clear sedation policy for cardiac procedures, leading to inconsistent drug use, inadequate staff training …
 Frimley Park Hospital All Responded 1/1
13 Oct 2016 Robert Davidson
Care home staff lacked basic emergency training, including 999 procedures and CPR. Health Care Assistants had insufficient experience, …
 Aran Court Care Centre Care Quality Commission Department of Health and Social … Jubilee Gardens Care Centre NHS England All Responded 5/5
13 Oct 2016 Roy Hoey
Concerns arose from staff confusion regarding the interpretation and application of safer custody guidance, specifically when to open …
 National Offender Management Service All Responded 1/1
12 Oct 2016 Wayne Cornlouer
An emergency coding system for medical emergencies was not initially in Night Orders, raising concerns if all staff …
 HMP Portland All Responded 1/1
11 Oct 2016 Tyrone Lock
Police failed to classify a vulnerable person exhibiting clear distress as such, treating him as an absconding suspect. …
 West Mercia Police All Responded 2/1
11 Oct 2016 Vichal Tonpradit
A raised section of tarmac separating a motorway slip road from the main carriageway caused a motorcyclist to …
 Highways England All Responded 1/1
10 Oct 2016 Ann Hardman
The DVT scan protocol relies on GP referrals for follow-up, risking patients missing re-scans. An automatic re-booking system …
 Isle of Wight NHS Trust All Responded 1/1
7 Oct 2016 Debrata Sircar
A significant delay in securing a mental health bed and conducting an MHA assessment, coupled with the absence …
 London Royal Borough of Greenwich Oxleas NHS Mental Trust Partially Responded 1/2
5 Oct 2016 Colin Wellings
Current legislation exempts older, powerful vehicles from essential safety requirements like helmets or seatbelts, posing significant risks to …
 Department for Transport All Responded 1/1
4 Oct 2016 Haydn Burton
Prison staff failed to implement ACCT plans effectively and observations were inadequate. Confidentiality rules for Listeners were unclear …
 HM Prison Service Samaritans Partially Responded 1/2
3 Oct 2016 Amy El-Keria
Hounslow Social Services misunderstood their ongoing welfare role for a child placed far from home and failed to …
 Department of Health and Social … Hounslow Borough Council All Responded 5/2
20 Sep 2016 Liam Lambert
ACCT documents were incomplete, not properly utilized, and closed prematurely. Resourcing issues compromised officers' ability to ensure prisoner …
 National Offender Management Service HMP YOI Glen Parva Partially Responded 1/2
19 Sep 2016 Daphne McCorkle
A critical gap exists in night-time care provision for patients requiring frequent turning to prevent pressure sores, as …
 London Borough of Lewisham Adult … NHS Lewisham Clinical Commissioning Group Partially Responded 1/2
16 Sep 2016 Denis Cronin
Significant failings in dive training, planning, and risk assessment led to an unqualified diver teaching an inexperienced individual. …
 British Sub Aqua Club Dulwich Dive Club All Responded 2/2
15 Sep 2016 Richard Breatnach
Online medication prescribing allowed applicants to provide false information without verification, leading to excessive and inappropriate prescription of …
 H R Healthcare Limited NHS England Partially Responded 1/2
13 Sep 2016 Arthur Adley
Safeguarding systems in care homes were inadequate to prevent a resident who posed a risk to others from …
 Department of Health and Social … All Responded 1/1
7 Sep 2016 Louise Turner
Inadequate post-discharge mental health care, ineffective support systems, and inappropriate expectations for patients to initiate contact were identified. …
 Department of Health and Social … Devon Partnership Trust NHS Northern Eastern and Western … All Responded 1/3
7 Sep 2016 Dildar Shariff
There is a critical lack of national awareness and NICE guideline inclusion regarding the increased haemorrhage risk in …
 Department of Health and Social … N.I.C.E Pennine Acute NHS Trust Partially Responded 2/3
7 Sep 2016 Christopher Jones
Inadequate mental health care planning resulted in patients being without consultant review for extended periods post-discharge. Increased demand …
 Betsi Cadwaladr University Health Board All Responded 1/1
7 Sep 2016 Glen Jordan
Staff failed to remove a holdall bag with an attached strap, a ligature risk, from a patient's room, …
 Care Quality Commission Dudley and Walsall Mental Health … Partially Responded 1/2
6 Sep 2016 Warren Sampson
Prison healthcare lacked consistent input in ACCT reviews and a follow-up process for missed screenings. Officers were also …
 Care UK HMP Partially Responded 1/2
6 Sep 2016 David Wade
The provided text is incomplete and does not detail specific concerns.
 NHS England All Responded 1/1
6 Sep 2016 Samantha Hopkins
Critical trial exclusions, such as for pregnant women, were overlooked due to insufficient prominence on drug packet warnings …
 South Central Ambulance Service Warwick Medical School All Responded 2/2
5 Sep 2016 Imad Hassan
There is no formal backup plan for PCI procedures when primary hospitals lack capacity, and no agreed pathways …
 ABMU Health Board Cardiff and Vale Health Board CWM Taff Health Board Partially Responded 2/3
30 Aug 2016 Harry Gill
The NHS 111 vomiting pathways were not robust, leading to inappropriate responses in most calls and failing to …
 NHS Digital All Responded 1/1
26 Aug 2016 Kyles Lowes
Long emergency care journey times and a single paramedic crew after 10 pm in a busy area create …
 NEAS NHS Trust NHS Northumberland Clinical Commissioning Group Partially Responded 1/2
26 Aug 2016 Pamela Conway
Persistent and unacceptable delays in patient offloading from ambulances at hospitals continue to render ambulance resources unavailable for …
 Betsi Cadwaladr University Health Board Welsh Ambulance Services NHS Trust All Responded 2/2
26 Aug 2016 Raymond Woodward Medicines and Healthcare Products Regulatory … All Responded 2/1
26 Aug 2016 Maureen Flynn
A critical falls risk assessment was not completed, and staff were unaware of this omission due to a …
 Stepping Hill Hospital All Responded 1/1
24 Aug 2016 Joyce Ravenhill
A lack of operational policy prevented effective communication of an urgent doctor's appointment need between triage nurses, relying …
 North West Ambulance Service Trust … All Responded 1/1
23 Aug 2016 Stephen Cahill
Easy access to the railway line through inadequate fencing and an access gate poses a risk, and a …
 Network Rail All Responded 1/1
23 Aug 2016 Michael Dundon
Unsupervised liquid-absorbing crystals, mistaken for consumables, caused a patient's death. The risks of these sachets are not fully …
 Department of Health and Social … All Responded 1/1
19 Aug 2016 Nathan Lowe Hertfordshire Partnership University NHS Foundation … All Responded 1/1
19 Aug 2016 Amanda Coppen Estates and Property Housing and … Greater London Authority Lands Royal Borough of Greenwich Surface Transport Transport for London All Responded 1/6
Frederick Squires
All Responded
31 Oct 2016 · Milton Keynes · 1/1 responses
A lack of clear clinical guidance on when to reintroduce Warfarin after a head injury risks either premature commencement leading to bleeding, or delayed commencement …
N.I.C.E
Alfred Grimshaw
All Responded
28 Oct 2016 · Blackburn, Hyndham and Ribble Valley · 1/1 responses
A critical hip fracture was missed during initial assessment and an X-ray report. Pre-discharge physiotherapy and occupational therapy reviews were documented but not conducted, leading …
East Lancashire Healthcare NHS …
Samuel Carroll
All Responded
27 Oct 2016 · North Yorkshire (West) · 2/2 responses
Police and ambulance services failed to obtain consent to inform family or friends about a patient's suicidal ideation and hospital attendance, leaving them unaware of …
North Yorkshire Police Yorkshire Ambulance Service NHS …
Alfie Rose
All Responded
26 Oct 2016 · Birmingham and Solihull · 2/2 responses
Poor inter-hospital communication and ineffective information sharing systems led to missed opportunities for patient transfer and treatment. Clinicians require better education on neurological referral protocols.
Dudley Group of Hospitals … University Hospitals Birmingham NHS …
Matthew Llewellyn-Jones
All Responded
25 Oct 2016 · Exeter and Greater Devon · 1/1 responses
Ward security remains compromised by breached "locked doors" and predictable patient observations, deviating from best practice. The note-recording system lacks mandatory fields for crucial carer/family …
Devon Partnership Trust
Kevin Hefferman
All Responded
25 Oct 2016 · Hertfordshire · 1/1 responses
Persistent standing water and water flow across a specific carriageway section contributed to numerous past collisions, posing an ongoing danger to road users, especially during …
Highways England
Ivy Atkin
All Responded
25 Oct 2016 · Nottinghamshire · 2/2 responses
A regulatory loophole allows individuals with criminal convictions to become "Nominated Individuals" for care homes without independent suitability assessment, particularly in small, family-owned companies.
Care Quality Commission Department of Health and …
Richard Walsh
All Responded
25 Oct 2016 · London Inner (South) · 4/3 responses
Systemic failures and inadequate communication processes between police, courts, healthcare, and prison services led to crucial mental health assessment information not being effectively shared or …
Department of Health and … Hampshire County Council Ministry of Justice
Jane Reason
All Responded
25 Oct 2016 · Birmingham and Solihull · 4/4 responses
There is a critical shortage of public access defibrillators in colleges and schools, and a need for increased public education on their placement and effective …
Department of Health and … Resuscitation Council NHS England Department for Education
Joan Green
All Responded
24 Oct 2016 · Lincolnshire (Central) · 1/1 responses
The junction design is "challenging" and dangerous, evidenced by a history of fatal collisions and observed "near misses." There were also significant delays for HGVs …
Lincolnshire County Council
Margaret Dempsie
All Responded
24 Oct 2016 · Leicester City and Leicestershire South · 3/2 responses
Hospital discharge letters contained significant inaccuracies and omissions, often completed by junior doctors who hadn't seen the patient, risking serious care mistakes for vulnerable patients.
NHS England University Hospitals of Leicester …
Colin Garth
All Responded
20 Oct 2016 · Manchester (West) · 1/1 responses
The report text does not detail specific concerns.
Bolton NHS Trust
Victoria Halliday
All Responded
20 Oct 2016 · Leicester City and Leicestershire South · 3/1 responses
A lack of local female psychiatric intensive care beds, ineffective community psychiatric nursing, and inadequate community support for complex patients left individuals unsupported. Care Programme …
Leicestershire Partnership NHS Trust
Benjamin Orrill
All Responded
19 Oct 2016 · Leicester City and Leicestershire South · 2/2 responses
The lack of a regulatory body for advanced nurse practitioners, leading to inconsistent appraisal, revalidation, and potential unsupervised practice, poses a significant risk to patient …
NHS England Nursing and Midwifery Council
Isaac Brocklehurst
All Responded
18 Oct 2016 · West Yorkshire (West) · 1/1 responses
There is a concern about the safety of pedestrian gaps in a low perimeter wall within a communal grassed area, requiring review to protect playing …
Incommunities
Captain James Bedforth
Partially Responded
18 Oct 2016 · South Yorkshire (West) · 1/2 responses
Inadequate DVT scanning guidelines and poor safety-netting led to missed diagnosis. Delayed assessment in ED, issues with anticoagulation management, and poor note-keeping further compromised care.
Barnsley Hospital NHS Trust Department of Health and …
Peter Keep
All Responded
14 Oct 2016 · Surrey · 1/1 responses
The hospital lacked a clear sedation policy for cardiac procedures, leading to inconsistent drug use, inadequate staff training on anxiolytics, and no action plan for …
Frimley Park Hospital
Robert Davidson
All Responded
13 Oct 2016 · Birmingham and Solihull · 5/5 responses
Care home staff lacked basic emergency training, including 999 procedures and CPR. Health Care Assistants had insufficient experience, and vital patient information like PICA behaviour …
Aran Court Care Centre Care Quality Commission Department of Health and … Jubilee Gardens Care Centre NHS England
Roy Hoey
All Responded
13 Oct 2016 · Liverpool and Wirral · 1/1 responses
Concerns arose from staff confusion regarding the interpretation and application of safer custody guidance, specifically when to open an ACCT plan, requiring clarification on mandatory …
National Offender Management Service
Wayne Cornlouer
All Responded
12 Oct 2016 · Dorset · 1/1 responses
An emergency coding system for medical emergencies was not initially in Night Orders, raising concerns if all staff are now aware of its recent inclusion …
HMP Portland
Tyrone Lock
All Responded
11 Oct 2016 · Shropshire, Telford and Wrekin · 2/1 responses
Police failed to classify a vulnerable person exhibiting clear distress as such, treating him as an absconding suspect. This led to a missed opportunity for …
West Mercia Police
Vichal Tonpradit
All Responded
11 Oct 2016 · Hertfordshire · 1/1 responses
A raised section of tarmac separating a motorway slip road from the main carriageway caused a motorcyclist to fall, leading to fatal injuries.
Highways England
Ann Hardman
All Responded
10 Oct 2016 · Isle of Wight · 1/1 responses
The DVT scan protocol relies on GP referrals for follow-up, risking patients missing re-scans. An automatic re-booking system from the ultrasound department is needed to …
Isle of Wight NHS …
Debrata Sircar
Partially Responded
7 Oct 2016 · London Inner (South) · 1/2 responses
A significant delay in securing a mental health bed and conducting an MHA assessment, coupled with the absence of an interim care plan, compromised care …
London Royal Borough of … Oxleas NHS Mental Trust
Colin Wellings
All Responded
5 Oct 2016 · South Wales Central · 1/1 responses
Current legislation exempts older, powerful vehicles from essential safety requirements like helmets or seatbelts, posing significant risks to riders and other road users.
Department for Transport
Haydn Burton
Partially Responded
4 Oct 2016 · Hampshire (Central) · 1/2 responses
Prison staff failed to implement ACCT plans effectively and observations were inadequate. Confidentiality rules for Listeners were unclear regarding active suicide plans, and the NOMIS …
HM Prison Service Samaritans
Amy El-Keria
All Responded
3 Oct 2016 · East Sussex · 5/2 responses
Hounslow Social Services misunderstood their ongoing welfare role for a child placed far from home and failed to assess for support, neglecting family contact issues.
Department of Health and … Hounslow Borough Council
Liam Lambert
Partially Responded
20 Sep 2016 · Leicester City and Leicestershire South · 1/2 responses
ACCT documents were incomplete, not properly utilized, and closed prematurely. Resourcing issues compromised officers' ability to ensure prisoner safety, especially for vulnerable young men.
National Offender Management Service HMP YOI Glen Parva
Daphne McCorkle
Partially Responded
19 Sep 2016 · London Inner (South) · 1/2 responses
A critical gap exists in night-time care provision for patients requiring frequent turning to prevent pressure sores, as neither district nurses nor agency carers provide …
London Borough of Lewisham … NHS Lewisham Clinical Commissioning …
Denis Cronin
All Responded
16 Sep 2016 · Leicester City and South Leicestershire · 2/2 responses
Significant failings in dive training, planning, and risk assessment led to an unqualified diver teaching an inexperienced individual. Important safety information was ignored, and equipment …
British Sub Aqua Club Dulwich Dive Club
Richard Breatnach
Partially Responded
15 Sep 2016 · Brighton and Hove · 1/2 responses
Online medication prescribing allowed applicants to provide false information without verification, leading to excessive and inappropriate prescription of an addictive drug without patient contact or …
H R Healthcare Limited NHS England
Arthur Adley
All Responded
13 Sep 2016 · London (North) · 1/1 responses
Safeguarding systems in care homes were inadequate to prevent a resident who posed a risk to others from causing harm.
Department of Health and …
Louise Turner
All Responded
7 Sep 2016 · Exeter and Greater Devon · 1/3 responses
Inadequate post-discharge mental health care, ineffective support systems, and inappropriate expectations for patients to initiate contact were identified. Devon also lacks female intensive psychiatric care …
Department of Health and … Devon Partnership Trust NHS Northern Eastern and …
Dildar Shariff
Partially Responded
7 Sep 2016 · Manchester (North) · 2/3 responses
There is a critical lack of national awareness and NICE guideline inclusion regarding the increased haemorrhage risk in haemodialysis or uremia patients, potentially leading to …
Department of Health and … N.I.C.E Pennine Acute NHS Trust
Christopher Jones
All Responded
7 Sep 2016 · North Wales (East and Central) · 1/1 responses
Inadequate mental health care planning resulted in patients being without consultant review for extended periods post-discharge. Increased demand on services also created staff cover deficiencies.
Betsi Cadwaladr University Health …
Glen Jordan
Partially Responded
7 Sep 2016 · Black Country · 1/2 responses
Staff failed to remove a holdall bag with an attached strap, a ligature risk, from a patient's room, highlighting a lapse in safety checks.
Care Quality Commission Dudley and Walsall Mental …
Warren Sampson
Partially Responded
6 Sep 2016 · Essex · 1/2 responses
Prison healthcare lacked consistent input in ACCT reviews and a follow-up process for missed screenings. Officers were also not adequately familiar with local directives.
Care UK HMP
David Wade
All Responded
6 Sep 2016 · Blackburn, Hyndburn and Ribble Valley · 1/1 responses
The provided text is incomplete and does not detail specific concerns.
NHS England
Samantha Hopkins
All Responded
6 Sep 2016 · Portsmouth and South East Hampshire · 2/2 responses
Critical trial exclusions, such as for pregnant women, were overlooked due to insufficient prominence on drug packet warnings and lack of guidance for highlighting these …
South Central Ambulance Service Warwick Medical School
Imad Hassan
Partially Responded
5 Sep 2016 · South Wales Central · 2/3 responses
There is no formal backup plan for PCI procedures when primary hospitals lack capacity, and no agreed pathways for accessing critical care beds outside Wales …
ABMU Health Board Cardiff and Vale Health … CWM Taff Health Board
Harry Gill
All Responded
30 Aug 2016 · Blackburn, Hyndburn and Ribble Valley · 1/1 responses
The NHS 111 vomiting pathways were not robust, leading to inappropriate responses in most calls and failing to ensure adequate patient care.
NHS Digital
Kyles Lowes
Partially Responded
26 Aug 2016 · North Northumberland · 1/2 responses
Long emergency care journey times and a single paramedic crew after 10 pm in a busy area create significant risk of delayed responses. The proposed …
NEAS NHS Trust NHS Northumberland Clinical Commissioning …
Pamela Conway
All Responded
26 Aug 2016 · North Wales (East and Central) · 2/2 responses
Persistent and unacceptable delays in patient offloading from ambulances at hospitals continue to render ambulance resources unavailable for other calls, creating ongoing risks to public …
Betsi Cadwaladr University Health … Welsh Ambulance Services NHS …
Raymond Woodward
All Responded
26 Aug 2016 · Birmingham and Solihull · 2/1 responses
Medicines and Healthcare Products …
Maureen Flynn
All Responded
26 Aug 2016 · Manchester (South) · 1/1 responses
A critical falls risk assessment was not completed, and staff were unaware of this omission due to a lack of system to alert them. The …
Stepping Hill Hospital
Joyce Ravenhill
All Responded
24 Aug 2016 · Cheshire · 1/1 responses
A lack of operational policy prevented effective communication of an urgent doctor's appointment need between triage nurses, relying instead on automated electronic information.
North West Ambulance Service …
Stephen Cahill
All Responded
23 Aug 2016 · Bedfordshire and Luton · 1/1 responses
Easy access to the railway line through inadequate fencing and an access gate poses a risk, and a recommended review of these security measures has …
Network Rail
Michael Dundon
All Responded
23 Aug 2016 · West Yorkshire (East) · 1/1 responses
Unsupervised liquid-absorbing crystals, mistaken for consumables, caused a patient's death. The risks of these sachets are not fully understood, necessitating improved risk assessment, staff awareness, …
Department of Health and …
Nathan Lowe
All Responded
19 Aug 2016 · City of London · 1/1 responses
Hertfordshire Partnership University NHS …
Amanda Coppen
All Responded
19 Aug 2016 · London Inner (South) · 1/6 responses
Estates and Property Housing … Greater London Authority Lands Royal Borough of Greenwich Surface Transport Transport for London