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Prevention of Future Deaths
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Total: 4,628 Responded: 4,628 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.
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4,628 reports · Page 75 of 93
Date Deceased Addressee(s) Status Responses
7 Aug 2016 Rohan Fitzsimons
Insufficient inpatient mental health beds, influenced by funding, led to significant delays in Mental Health Act assessments, posing …
 Avon and Wiltshire Mental Health … Bristol Clinical Commissioning Group Care Quality Commission Partially Responded 1/3
4 Aug 2016 Susan Hamlett Network Rail All Responded 1/1
3 Aug 2016 Winston Harris Birmingham City Council Sandwell and West Birmingham Hospitals … All Responded 2/2
1 Aug 2016 Joshua Knox-Hooke North Middlesex University Hospital NHS … All Responded 1/1
1 Aug 2016 Pamela Gressman
There was insufficient consideration of physical effects from reported foreign body ingestion, leading to an absence of a …
 Tees, Esk and Wear Valleys … All Responded 1/1
29 Jul 2016 Danny Sweet Cornwall Partnership Foundation Trust All Responded 1/1
29 Jul 2016 Miles Abel Department of Health and Social … Endless Street Surgery All Responded 2/2
28 Jul 2016 Leslie Morrison Central Manchester University Hospitals NHS … Manchester Mental Health and Social … Regard Care Partially Responded 1/3
27 Jul 2016 James Hedge
Insulin pump guidance inadequately highlights misuse dangers from incorrect cartridge insertion, and patient education fails to emphasize the …
 Medicines and Healthcare Products Regulatory … NHS England NHS Wales Roche Diagnostics Limited All Responded 4/4
27 Jul 2016 Cerith Pugh
Referrals to consultants were inappropriately handled by middle-grade doctors, and essential liver function tests were declined due to …
 Hywel Dda University Health Board All Responded 1/1
26 Jul 2016 Margaret Tuck
Multiple failures included an absent falls prevention care plan, incomplete post-fall observations, confusion over nurse responsibility, and delayed …
 Royal London Hospital All Responded 1/1
26 Jul 2016 Leslie Matthews County Durham and Darlington NHS … Medicines and Healthcare Products Regulatory … Patient Safety Lead Partially Responded 2/3
26 Jul 2016 Rebecca Gilbank Independence Homes Limited All Responded 1/1
26 Jul 2016 Terence Adams
Inadequate checking and sharing of prison risk assessments, healthcare staff unawareness of risk score protocols, and failure to …
 Care UK HMP Pentonville Partially Responded 1/2
26 Jul 2016 Lee Grimes
Home health care failed to act on overdose disclosures and ensure follow-up with mental health services, compounded by …
 5 Boroughs Partnership NHS Foundation … Next Stage Warrington Partially Responded 2/3
25 Jul 2016 Yogalakshmi Sinnaiah
Pedestrians commonly cross the road unsafely at a pelican crossing by "cutting the corner," leading to near misses, …
 Hampshire County Council Department for Transport Partially Responded 1/2
25 Jul 2016 Marjorie Nesbitt
Carers lacked training and clear guidance on how to manage unusual and difficult situations, specifically regarding an overheating …
 Sheffield City Council All Responded 1/1
25 Jul 2016 Alfie Gray
Inadequate lifeguard provision, including insufficient numbers, lack of medical training, and uncommunicated off-duty periods, created significant safety risks …
 British Travel Agents All Responded 1/1
25 Jul 2016 Patricia Cleghorn
The unavailability of acute mental health beds led to a vulnerable patient being cared for in the community …
 Birmingham and Solihull Mental Health … Care Quality Commission NHS England: Department of Health All Responded 4/3
22 Jul 2016 Alan Stead
Delays in taking and testing blood samples from prisoners at HMP Dovegate were identified, which could have serious …
 Care UK All Responded 1/1
22 Jul 2016 Stephen Bird
Patient records were incomplete and inconsistent, and the hospital's internal investigation report contained factual assumptions conflicting with documentation, …
 BMI The Shelburne Hospital All Responded 1/1
21 Jul 2016 Nathan Charman
The winter maintenance policy and decision-making process inadequately addressed extreme or "microclimatic" road conditions, and the incident failed …
 Durham County Council All Responded 1/1
19 Jul 2016 Patricia Mercieca
Call handlers required refresher training on contacting resident managers during emergencies and lacked a protocol for raising immediate …
 Tunstall Response All Responded 1/1
15 Jul 2016 Margaret Gleeson
Hospital weekend staffing levels were inadequate, leading to poor patient care. The MEWS tool was inaccurately scored and …
 Wrightington, Wigan and Leigh Teaching … All Responded 1/1
15 Jul 2016 Sydney Neil
After a patient collapsed in a GP surgery, there was inadequate ventilation, no suction, and no oxygen provided …
 Birmingham Cross City Clinical Commissioning … NHS England Wychall Lane Surgery All Responded 3/3
15 Jul 2016 Leilani Chute
Junior doctors used non-standard medical practice without consultant knowledge, and consent for women in labor was not truly …
 St Richard’s Hospital Western Sussex Hospital NHS Trust All Responded 1/2
15 Jul 2016 James Kane
A patient died due to a drain, and a scan potentially could have reduced this risk, indicating a …
 County Durham and Darlington NHS … Department of Health and Social … All Responded 2/2
14 Jul 2016 Fred Whittaker
A patient was erroneously re-prescribed medication due to the lack of a system for recording reasons for stopping …
 Heaton Moor Medical Centre NHS England Partially Responded 1/2
14 Jul 2016 Harold Goulding
Communication breakdown between the care home, GP, and anti-coagulation clinic led to medication mismanagement. The care home lacked …
 Alexander Court Care Central All Responded 1/1
14 Jul 2016 Patrick Curran
Hospital practice condoned nurse-led post-operative reviews and patient discharges without adequate medical overview, even for unwell patients, potentially …
 South Manchester University Hospital NHS … All Responded 1/1
12 Jul 2016 Alice Gross
UK police lack mandatory foreign conviction checks for all arrestees and UK nationals. There are concerns about inadequate …
 Home Office All Responded 1/1
12 Jul 2016 Steven Billington
No specific concerns are detailed in the provided text.
 Home Office Secretary for Communities and Local … All Responded 2/2
11 Jul 2016 Michael Williams
Prison staff missed mandated observations and used predictable intervals for checks. There was an inappropriate delay in responding …
 HMP Leicester All Responded 1/1
4 Jul 2016 Thomas Pearson
A patient was prescribed fluticasone, increasing pneumonia risk without benefit due to a non-raised eosinophil count. The coroner …
 Doncaster Royal Infirmary All Responded 1/1
4 Jul 2016 Henry Hicks
Police officers failed to identify a situation as a pursuit and seek authorisation, contrary to the jury's determination, …
 Metropolitan Police All Responded 1/1
1 Jul 2016 George Punton
No specific concerns are detailed in the provided text.
 Highway and Transport Wiltshire Council All Responded 1/1
30 Jun 2016 Terence Stilges
Repeated incorrect labelling of troponin blood samples resulted in unavailable critical diagnostic information, contributing to delayed diagnosis and …
 Heart of England NHS Foundation … NHS England Partially Responded 1/2
30 Jun 2016 Luisa Mendes
Police call handlers inappropriately categorised violent incidents, and there were no formal handover procedures or training for shift …
 Chief Constable of Warwickshire Police All Responded 1/1
30 Jun 2016 Dominic Smith
Systemic failures included inadequate antenatal GBS screening and prophylaxis, alongside hospital issues such as poor communication, protocol non-adherence, …
 Department of Health and Social … N.I.C.E Pennine Acute Hospitals NHS Trust Royal College of Obstetricians Royal College of Paediatricians Partially Responded 2/5
29 Jun 2016 Lee Davies
Hostel staff lacked specific training on monitoring and safeguarding residents found after illicit drug use, instead only focusing …
 Wallich Centre All Responded 1/1
28 Jun 2016 Tommi-Ray Vigrass
A paediatric doctor made an erroneous extubation decision without consulting a consultant. There were also delays in contacting …
 Care Quality Commission Walsall Healthcare NHS Trust Partially Responded 1/2
28 Jun 2016 David Little
Hospital staff failed to maintain clear radiology records, misidentified a patient, and lacked training to recognise blocked bowel …
 Tameside Hospital NHS Foundation Trust All Responded 1/1
24 Jun 2016 William Nute
Delays in emergency service attendance and patient transfer, coupled with inadequate 999 call triage and police notification, led …
 Devon and Cornwall Police South Western Ambulance Service Partially Responded 1/2
23 Jun 2016 Michael Younghusband
A railway crossing point was in a poor state, with a section standing proud of the track, presenting …
 Great Western Railway All Responded 1/1
22 Jun 2016 Malcolm Bennett
Staff at the care home delayed calling an ambulance for three hours after a significant injury, despite the …
 Borough Care Ltd All Responded 1/1
20 Jun 2016 Michael Hutchence
Concerns included frequent, unnecessary ward transfers, poor medical record-keeping, care by unqualified staff, and inaccurate anticoagulant dosing due …
 Stockport NHS Foundation Trust All Responded 1/1
16 Jun 2016 Valerie Ellis
Inadequate discharge counselling for a vulnerable patient on medication, coupled with concerns about 111 health advisor training and …
 Western Sussex Hospital NHS Trust All Responded 3/1
13 Jun 2016 Laura McRory
The Trust lacked a clear process for employees seeking mental health care, especially regarding confidentiality and external referrals. …
 North East London Foundation Trust All Responded 1/1
13 Jun 2016 Kevin Dermott
Serious deficiencies in prison mental health care included misdiagnosis, lack of specialist treatment, uncompleted psychiatric care plans, and …
 Department for Health NHS England All Responded 3/2
9 Jun 2016 Matthew Gunn
An epileptic event experienced by an employee at work was not officially recorded, raising concerns about incident reporting …
 W M Morrisons PLC All Responded 1/1
Rohan Fitzsimons
Partially Responded
7 Aug 2016 · Avon · 1/3 responses
Insufficient inpatient mental health beds, influenced by funding, led to significant delays in Mental Health Act assessments, posing a risk of individuals taking their own …
Avon and Wiltshire Mental … Bristol Clinical Commissioning Group Care Quality Commission
Susan Hamlett
All Responded
4 Aug 2016 · Bedfordshire and Luton · 1/1 responses
Network Rail
Winston Harris
All Responded
3 Aug 2016 · Birmingham and Solihull · 2/2 responses
Birmingham City Council Sandwell and West Birmingham …
Joshua Knox-Hooke
All Responded
1 Aug 2016 · London Greater (East) · 1/1 responses
North Middlesex University Hospital …
Pamela Gressman
All Responded
1 Aug 2016 · County Durham and Darlington · 1/1 responses
There was insufficient consideration of physical effects from reported foreign body ingestion, leading to an absence of a clear treatment and observation plan for physical …
Tees, Esk and Wear …
Danny Sweet
All Responded
29 Jul 2016 · Cornwall and the Isles of Scilly · 1/1 responses
Cornwall Partnership Foundation Trust
Miles Abel
All Responded
29 Jul 2016 · Wiltshire and Swindon · 2/2 responses
Department of Health and … Endless Street Surgery
Leslie Morrison
Partially Responded
28 Jul 2016 · Manchester City · 1/3 responses
Central Manchester University Hospitals … Manchester Mental Health and … Regard Care
James Hedge
All Responded
27 Jul 2016 · South Wales Central · 4/4 responses
Insulin pump guidance inadequately highlights misuse dangers from incorrect cartridge insertion, and patient education fails to emphasize the rapid life-threatening nature of hyperglycaemia.
Medicines and Healthcare Products … NHS England NHS Wales Roche Diagnostics Limited
Cerith Pugh
All Responded
27 Jul 2016 · Carmarthenshire and Pembrokeshire · 1/1 responses
Referrals to consultants were inappropriately handled by middle-grade doctors, and essential liver function tests were declined due to a rigid demand management policy, lacking a …
Hywel Dda University Health …
Margaret Tuck
All Responded
26 Jul 2016 · London Inner (North) · 1/1 responses
Multiple failures included an absent falls prevention care plan, incomplete post-fall observations, confusion over nurse responsibility, and delayed investigation of confusion, contributing to undetected deterioration.
Royal London Hospital
Leslie Matthews
Partially Responded
26 Jul 2016 · County Durham and Darlington · 2/3 responses
County Durham and Darlington … Medicines and Healthcare Products … Patient Safety Lead
Rebecca Gilbank
All Responded
26 Jul 2016 · Surrey · 1/1 responses
Independence Homes Limited
Terence Adams
Partially Responded
26 Jul 2016 · London Inner (North) · 1/2 responses
Inadequate checking and sharing of prison risk assessments, healthcare staff unawareness of risk score protocols, and failure to follow up on missed appointments contributed to …
Care UK HMP Pentonville
Lee Grimes
Partially Responded
26 Jul 2016 · Manchester West · 2/3 responses
Home health care failed to act on overdose disclosures and ensure follow-up with mental health services, compounded by inadequate staff training in managing overdose reports.
5 Boroughs Partnership NHS … Next Stage Warrington
Yogalakshmi Sinnaiah
Partially Responded
25 Jul 2016 · Portsmouth and South East Hampshire · 1/2 responses
Pedestrians commonly cross the road unsafely at a pelican crossing by "cutting the corner," leading to near misses, suggesting a need for physical barriers.
Hampshire County Council Department for Transport
Marjorie Nesbitt
All Responded
25 Jul 2016 · South Yorkshire (West) · 1/1 responses
Carers lacked training and clear guidance on how to manage unusual and difficult situations, specifically regarding an overheating client from a heater, leading to a …
Sheffield City Council
Alfie Gray
All Responded
25 Jul 2016 · West Sussex · 1/1 responses
Inadequate lifeguard provision, including insufficient numbers, lack of medical training, and uncommunicated off-duty periods, created significant safety risks for holidaymakers.
British Travel Agents
Patricia Cleghorn
All Responded
25 Jul 2016 · Birmingham and Solihull · 4/3 responses
The unavailability of acute mental health beds led to a vulnerable patient being cared for in the community with limited resources, alongside a failure to …
Birmingham and Solihull Mental … Care Quality Commission NHS England: Department of …
Alan Stead
All Responded
22 Jul 2016 · Staffordshire (South) · 1/1 responses
Delays in taking and testing blood samples from prisoners at HMP Dovegate were identified, which could have serious clinical consequences.
Care UK
Stephen Bird
All Responded
22 Jul 2016 · Buckinghamshire · 1/1 responses
Patient records were incomplete and inconsistent, and the hospital's internal investigation report contained factual assumptions conflicting with documentation, undermining its learning process.
BMI The Shelburne Hospital
Nathan Charman
All Responded
21 Jul 2016 · County Durham and Darlington · 1/1 responses
The winter maintenance policy and decision-making process inadequately addressed extreme or "microclimatic" road conditions, and the incident failed to prompt a formal review or learning.
Durham County Council
Patricia Mercieca
All Responded
19 Jul 2016 · London Inner (West) · 1/1 responses
Call handlers required refresher training on contacting resident managers during emergencies and lacked a protocol for raising immediate concerns when unable to get a response …
Tunstall Response
Margaret Gleeson
All Responded
15 Jul 2016 · Manchester (West) · 1/1 responses
Hospital weekend staffing levels were inadequate, leading to poor patient care. The MEWS tool was inaccurately scored and poorly understood, indicating a need for refresher …
Wrightington, Wigan and Leigh …
Sydney Neil
All Responded
15 Jul 2016 · Birmingham and Solihull · 3/3 responses
After a patient collapsed in a GP surgery, there was inadequate ventilation, no suction, and no oxygen provided for 8 minutes, raising concerns about resuscitation …
Birmingham Cross City Clinical … NHS England Wychall Lane Surgery
Leilani Chute
All Responded
15 Jul 2016 · West Sussex · 1/2 responses
Junior doctors used non-standard medical practice without consultant knowledge, and consent for women in labor was not truly informed. Crucially, these issues were not identified …
St Richard’s Hospital Western Sussex Hospital NHS …
James Kane
All Responded
15 Jul 2016 · County Durham and Darlington · 2/2 responses
A patient died due to a drain, and a scan potentially could have reduced this risk, indicating a need for further consideration of policy changes …
County Durham and Darlington … Department of Health and …
Fred Whittaker
Partially Responded
14 Jul 2016 · Manchester (South) · 1/2 responses
A patient was erroneously re-prescribed medication due to the lack of a system for recording reasons for stopping drugs and poor prescription management, a risk …
Heaton Moor Medical Centre NHS England
Harold Goulding
All Responded
14 Jul 2016 · London (East) · 1/1 responses
Communication breakdown between the care home, GP, and anti-coagulation clinic led to medication mismanagement. The care home lacked systems to inform agencies of new GPs …
Alexander Court Care Central
Patrick Curran
All Responded
14 Jul 2016 · Manchester (South) · 1/1 responses
Hospital practice condoned nurse-led post-operative reviews and patient discharges without adequate medical overview, even for unwell patients, potentially leading to missed diagnoses like pneumonia.
South Manchester University Hospital …
Alice Gross
All Responded
12 Jul 2016 · London Inner (West) · 1/1 responses
UK police lack mandatory foreign conviction checks for all arrestees and UK nationals. There are concerns about inadequate international data sharing, "watch list" management, and …
Home Office
Steven Billington
All Responded
12 Jul 2016 · Manchester (West) · 2/2 responses
No specific concerns are detailed in the provided text.
Home Office Secretary for Communities and …
Michael Williams
All Responded
11 Jul 2016 · Leicester City and Leicestershire South · 1/1 responses
Prison staff missed mandated observations and used predictable intervals for checks. There was an inappropriate delay in responding after a cell observation panel was blocked, …
HMP Leicester
Thomas Pearson
All Responded
4 Jul 2016 · South Yorkshire (East) · 1/1 responses
A patient was prescribed fluticasone, increasing pneumonia risk without benefit due to a non-raised eosinophil count. The coroner recommends reviewing inhaled steroid use in similar …
Doncaster Royal Infirmary
Henry Hicks
All Responded
4 Jul 2016 · London Inner (North) · 1/1 responses
Police officers failed to identify a situation as a pursuit and seek authorisation, contrary to the jury's determination, implying non-compliance with the Metropolitan Police Service's …
Metropolitan Police
George Punton
All Responded
1 Jul 2016 · Wiltshire and Swindon · 1/1 responses
No specific concerns are detailed in the provided text.
Highway and Transport Wiltshire …
Terence Stilges
Partially Responded
30 Jun 2016 · Birmingham and Solihull · 1/2 responses
Repeated incorrect labelling of troponin blood samples resulted in unavailable critical diagnostic information, contributing to delayed diagnosis and patient discharge before subsequent readmission with an …
Heart of England NHS … NHS England
Luisa Mendes
All Responded
30 Jun 2016 · Warwickshire · 1/1 responses
Police call handlers inappropriately categorised violent incidents, and there were no formal handover procedures or training for shift changes. The STORM computer system also lacked …
Chief Constable of Warwickshire …
Dominic Smith
Partially Responded
30 Jun 2016 · Manchester (North) · 2/5 responses
Systemic failures included inadequate antenatal GBS screening and prophylaxis, alongside hospital issues such as poor communication, protocol non-adherence, missed examinations, incorrect early warning scores, and …
Department of Health and … N.I.C.E Pennine Acute Hospitals NHS … Royal College of Obstetricians Royal College of Paediatricians
Lee Davies
All Responded
29 Jun 2016 · South Wales Central · 1/1 responses
Hostel staff lacked specific training on monitoring and safeguarding residents found after illicit drug use, instead only focusing on overdose recognition, leaving at-risk individuals unmonitored.
Wallich Centre
Tommi-Ray Vigrass
Partially Responded
28 Jun 2016 · Black Country · 1/2 responses
A paediatric doctor made an erroneous extubation decision without consulting a consultant. There were also delays in contacting a tertiary unit and an inadequate handover …
Care Quality Commission Walsall Healthcare NHS Trust
David Little
All Responded
28 Jun 2016 · Manchester (South) · 1/1 responses
Hospital staff failed to maintain clear radiology records, misidentified a patient, and lacked training to recognise blocked bowel symptoms. Poor inter-departmental communication and treating the …
Tameside Hospital NHS Foundation …
William Nute
Partially Responded
24 Jun 2016 · Cornwall · 1/2 responses
Delays in emergency service attendance and patient transfer, coupled with inadequate 999 call triage and police notification, led to an unmanaged incident scene and increased …
Devon and Cornwall Police South Western Ambulance Service
Michael Younghusband
All Responded
23 Jun 2016 · Exeter and Greater Devon · 1/1 responses
A railway crossing point was in a poor state, with a section standing proud of the track, presenting a significant tripping hazard for users.
Great Western Railway
Malcolm Bennett
All Responded
22 Jun 2016 · Manchester (South) · 1/1 responses
Staff at the care home delayed calling an ambulance for three hours after a significant injury, despite the care plan requiring immediate emergency department transfer, …
Borough Care Ltd
Michael Hutchence
All Responded
20 Jun 2016 · Manchester (South) · 1/1 responses
Concerns included frequent, unnecessary ward transfers, poor medical record-keeping, care by unqualified staff, and inaccurate anticoagulant dosing due to weight recording issues. Equipment shortages and …
Stockport NHS Foundation Trust
Valerie Ellis
All Responded
16 Jun 2016 · West Sussex · 3/1 responses
Inadequate discharge counselling for a vulnerable patient on medication, coupled with concerns about 111 health advisor training and imprecise algorithms. A call-back was prematurely closed …
Western Sussex Hospital NHS …
Laura McRory
All Responded
13 Jun 2016 · London (East) · 1/1 responses
The Trust lacked a clear process for employees seeking mental health care, especially regarding confidentiality and external referrals. There was also an inadequate safety plan …
North East London Foundation …
Kevin Dermott
All Responded
13 Jun 2016 · Cheshire · 3/2 responses
Serious deficiencies in prison mental health care included misdiagnosis, lack of specialist treatment, uncompleted psychiatric care plans, and poor communication during transfers. These systemic failures …
Department for Health NHS England
Matthew Gunn
All Responded
9 Jun 2016 · Gloucestershire · 1/1 responses
An epileptic event experienced by an employee at work was not officially recorded, raising concerns about incident reporting protocols.
W M Morrisons PLC