First raised 8 Apr 2014 in Audrey Kelly. Hazard: Lack of electronic access to primary care medical notes
Audrey Kelly (2014)
“neither they nor the hospital Emergency Departments, have direct access to GP [name redacted]”
This report (2026)
“Hospital doctors, including in the Emergency Department and Paediatrics, do not have electronic access to primary care medical notes e.g. GP notes, community mental health notes etc.”
First raised 23 Apr 2020 in Gordon Fenton. Hazard: Inadequate discharge decision analysis
Gordon Fenton (2020)
“There does not appear to be a formalised decision-making process in place involving both Trusts to review the treatment plan to determine the optimum medical and psychiatric care to suit the particular patient's needs.”
This report (2026)
“The investigation does not undertake any meaningful critical analysis of the decision- making process which resulted in her section being rescinded and her therefore being discharged notwithstanding family concerns in circumstances where no s17 leave had first been trialled”
First raised 16 Dec 2024 in Matthew Sheldrick (2): Prevention of Future Deaths Report. Hazard: Delayed transfer of acute mental health prisoners to secure units
Matthew Sheldrick (2): Prevention of Future Deaths Report (2024)
“There is a lack of inpatient beds leading to unacceptable wait times in A&E for those suffering with their mental health who are awaiting beds.”
15 Jan 2026 · Coroner Sarah Wood · Nottingham City and Nottinghamshire
First raised 5 Apr 2016 in Dorothy Imisson. Hazard: Non‑compliance with care plans and insufficient incident review
Dorothy Imisson (2016)
“(1) No appropriate care plan was developed by the District Nursing Service.”
This report (2026)
“ii) There are concerns over the level of compliance of care plans.”
Department of Health and Social Care
Dorothy Hoyberg14 Jan 2026 · Coroner Melanie Lee · Inner North London
First raised 22 May 2023 in Michael Bray: Prevention of future deaths report. Hazard: Delayed ambulance handover at hospitals
Michael Bray: Prevention of future deaths report (2023)
“long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future”
First raised 7 Mar 2022 in Jack Ritchie: Prevention of future deaths report. Hazard: Insufficient information on gambling risks and unlicensed sites
Jack Ritchie: Prevention of future deaths report (2022)
“The information available to [the deceased] was insufficient to prevent him gambling or to inform him of the help / treatments available”
First raised 14 May 2024 in Carol Divall: Prevention of future deaths report. Hazard: Inadequate pressure sore management and monitoring
Carol Divall: Prevention of future deaths report (2024)
“The RCA was insufficient and did not address all of the issues surrounding Mrs [name redacted] care”
This report (2026)
“Poor management of [the deceased]'s pain. In spite of sustaining a category 2 pressure sore and bilateral hip fractures whilst an in patient at EDGH, he was only receiving oral paracetamol.”
First raised 21 Feb 2019 in Terrence Smith. Hazard: Delayed recognition of excited delirium in ambulance dispatch
Terrence Smith (2019)
“The version of NHS Pathways currently in use is version 16 which does not enable operators to recognise potential ED / ABD and respond accordingly.”
This report (2026)
“Under the current NHS Pathways system, ABD does not have its own allocation pathway.”
First raised 17 Sept 2021 in Colin Blackburn: Prevention of future deaths report. Hazard: Delayed ACCT case review and inadequate process management
Colin Blackburn: Prevention of future deaths report (2021)
“(a) that no Initial ACCT Case Review was held within 24 hours of the Concern & Keep Safe form being completed on 21.6.19;”
First raised 29 Apr 2019 in Alfonso Sinclair. Hazard: Lack of staff alert system for odd behaviour
Alfonso Sinclair (2019)
“That there is no apparent system for staff to alert odd behaviour and then track an individual of concern on CCTV”
This report (2025)
“Recommended technological measures to detect and alert staff to the presence of persons on the tracks have not been implemented at Stratford station.”
First raised 20 Aug 2013 in Mohammed Chaudhury. Hazard: Inadequate repositioning and monitoring of at-risk patients
Mohammed Chaudhury (2013)
“Infected pressure sores may have been a cause of death and they were unusual in extent and severity.”
This report (2025)
“The evidence heard by the court indicated that though the care home had policies and guidance for the prevention and management of bed sores that was not followed by on-site care or nursing staff.”
His Majesty's Prison and Probation Service
Mesut Olgun10 Dec 2025 · Coroner David Reid · Worcestershire
First raised 14 May 2023 in Thomas Huntley: Prevention of future deaths report. Hazard: Lack of certified safer cells outside segregation unit
Thomas Huntley: Prevention of future deaths report (2023)
“The final area of concern is the lack of certified Safer Cells at HMP Winchester. The inquest heard evidence that these had either never existed at HMP Winchester or had not done so for many years.”
8 Dec 2025 · Coroner Linda Lee · Coventry and Warwickshire
First raised 25 Sept 2018 in Caitlin Huddleston and Skye Mitchell: Prevention of Future Deaths Report. Hazard: Young drivers carrying peer passengers increase collision risk
Caitlin Huddleston and Skye Mitchell: Prevention of Future Deaths Report (2018)
“(1) That [the deceased] was a driver with only 4 months driving experience after passing her driving test;”
First raised 11 Jan 2019 in Ricardo Holgate. Hazard: Unrestricted access to novel psychoactive substances in prison
Ricardo Holgate (2019)
“The new Governing Governor confirmed that further steps are necessary to improve the management of illicit substance misuse. He confirmed the prison requires CCTV on all wings and airport style scanners - one in reception for prisoners and one in the visitor area.”
His Majesty's Prison and Probation Service
Oliver Mulangala8 Dec 2025 · Coroner Jonathan Stevens · Surrey
First raised 3 May 2016 in Shalane Blackwood. Hazard: Widespread new psychoactive substances in prison
Shalane Blackwood (2016)
“That the use of New Psychoactive Substances (NPS) remains rife within the prison, and presentations such as Mr [name redacted] are not diminishing, and that the Substance Misuse Team requires further staff to be effective in future.”
What was promised after the earlier report
“The joint SOP which is scheduled to be trialled in August 2020 will apply to all patients within PCFT's older peoples' mental health inpatient wards. Both organisations will continue to work in partnership to identify, agree and establish working parameters for the Digital Health Team at TGH to support the physical health needs of older people receiving mental health care and treatment on Summers & Hague wards, of which Mr [name redacted] was a patient. The offering of Digital Health services will be conducted”
Sarah McGarrigle: Prevention of future deaths report (2022)
“the Consultant [name redacted] who reviewed the Deceased on Aspen Ward made the assumption that concern about the Deceased's capacity were raised in the context of her withdrawal from alcohol.”
This report (2026)
“In respect of findings made in relation to the care provided on the day before [the deceased]'s death, it remains unclear even after hearing all of the evidence how the investigators concluded (at page 24 of 44) '[t]here was no reason to doubt [the deceased]'s capacity at this stage'”
What was promised after the earlier report
“During [the deceased]'s admission to Aspen Ward, there was not enough consideration of [the deceased]'s historical mental health diagnoses, contextual clinical information from previous inpatient admissions and community care and her overall complexity. There is evidence of the MDT completing an assessment of [the deceased]'s mental health and associated risks over the course of her admission to Aspen Ward.”
This report (2026)
“The lack of beds, locally and nationally, for mental health admissions and the suggestion given in evidence that patients can be waiting in the open reception area for days or sometimes weeks for a bed.”
What was promised after the earlier report
“I expect individual trusts and local health systems to effectively assess and manage bed capacity, the 'flow' of patients being discharged or moving to another setting.”
Sapphire Bernard: Prevention of Future Deaths Report (2025)
“The lack of inpatient beds leading to the unacceptable wait time in A&E for those suffering with their mental health”
This report (2026)
“The lack of beds, locally and nationally, for mental health admissions and the suggestion given in evidence that patients can be waiting in the open reception area”
No published response from this organisation was found for the earlier report.
Ronald Farrington (2017)
“Failed to follow the advice of the tissue viability nurses as to turning and how to dress Mr [name redacted] sores”
This report (2026)
“There are concerns over the level of compliance of care plans.”
What was promised after the earlier report
“We have improved our systems to identify long running adult safeguarding enquiries and take actions to bring them to a satisfactory conclusion. In December 2016 15% of our adult safeguarding enquiries had been in progress for over 12 months. By December 2017 we had reduced this to 4%, despite the number of adult safeguarding enquiries we are undertaking having more than doubled over that period.”
Sidney Baker (2019)
“There were concerns that entries contained in Mr [name redacted] care plan were incorrect, including vital information contained on his weight monitoring sheet. Furthermore, the general quality of record keeping was poor.”
This report (2026)
“That there remain potential issues of poor record keeping.”
What was promised after the earlier report
“We will carry out a further comprehensive inspection within 12 months, to ensure action has been taken and the provider is no longer in breach.”
John Dickinson: Prevention of future deaths report (2021)
“(1) The record keeping was inconsistent and lacked detail on general wellbeing.”
This report (2026)
“That there remain potential issues of poor record keeping. ii) There are concerns over the level of compliance of care plans”
What was promised after the earlier report
“The provider has indicated they have also reviewed the quality of their own documentation and care records. In relation to food records, in addition to improved documentation, staff have also received additional training.”
Rebecca Begg: Prevention of future deaths report (2021)
“Failure to monitor compliance with care plans, and a lack of robust incident”
This report (2026)
“There are concerns over the level of compliance of care plans.”
No published response from this organisation was found for the earlier report.
Susan Bracegirdle: Prevention of future deaths report (2024)
“The inquest heard evidence that because Mrs [name redacted] was in a care home setting the District Nurses were responsible for management of her pressure ulcers.”
This report (2026)
“ii) There are concerns over the level of compliance of care plans.”
What was promised after the earlier report
“Whenever a District Nurse attends a resident at Stable Steps any advice in relation to the management of pressure ulcers is shared with the team via a Communication Book.”
This report (2026)
“Demand outstripped capacity. An ambulance should have reached [the deceased] within two hours but it took five and half.”
Geoffery Hoad: Prevention of future deaths report (2023)
“The ambulance service was called again at 23.45 hours and the call was again coded as a Category 3 call.”
This report (2026)
“An ambulance should have reached [the deceased] within two hours but it took five and half.”
What was promised after the earlier report
“we published our 'Delivery plan for recovering urgent and emergency care services' which aims to deliver sustained improvements in waiting times, including to reduce Category 2 response times (including for serious conditions such as heart attacks and strokes) to 30 minutes on average this year”
Simon Boyd: Prevention of Future Deaths Report (2024)
“notwithstanding the national target for Category 3 999 calls of 9 out of 10 responses within 120 minutes, the anticipated wait for a Category 3 ambulance on 1st June 2024 was around 3 hours and 15 minutes.”
This report (2026)
“Multiple attempts were made to find an ambulance resource for [the deceased] but LAS were unable to meet targets for Category 3 patients and were struggling to meet targets for Category 2 patients.”
No published response from this organisation was found for the earlier report.
Andrew Lewis: Prevention of Future Deaths Report (2024)
“SCAS has been at REAP 3 or above for 90% of this time period. They have been constantly at REAP 4 since 9 October 2024.”
This report (2026)
“On 19 June 2025 London Ambulance Service (LAS) were operating at REAP Level 4 (extreme pressure) and by 9am that day, targets were being breached.”
This report (2026)
“There is, in my view, a lack of adequate public health information and warning relating to the risks posed by unlicenced gambling sites.”
No published response from this organisation was found for the earlier report.
What was promised after the earlier report
“We acknowledge the unacceptable delay in dealing with the pressure sore. We note that category 2 pressure damage was first documented in Mrs [name redacted] health records on 20 September 2022, ten days before the referral to the TVN. In order to strengthen the approach regarding managing pressure sores, the Tissue Viability Team are supporting the ward to undertake a quality improvement (QI) project in relation to the prevention and management of pressure ulcers including the recognition of potential”
No published response from this organisation was found for the earlier report.
This report (2026)
“the ACCT process was not managed and implemented properly, e.g. supervising officers did not consistently acquaint themselves with case notes or history when completing reviews;”
What was promised after the earlier report
“The end date for the acceptance of paper referrals is 31st October 2021. From 1st November 2021, paper TAGs (Threshold Assessment Grid)1 will cease to be an option for referrals to the mental health team.”
Kayleigh Melhuish: Prevention of Future Deaths Report (2024)
“there was little understanding of the requirement to complete or review the care plan and support actions at every ACCT review not just the planned reviews;”
This report (2026)
“- the ACCT process was not managed and implemented properly, e.g. supervising officers did not consistently acquaint themselves with case notes or history when completing reviews;”
What was promised after the earlier report
“We have carefully considered the potential for implementing changes to SystmOne to include a tick-box to confirm the review of the care plan and support actions.”
What was promised after the earlier report
“LU station staff receive initial training and ongoing refresher training through our competency management system (CMS) to assist in identifying 'unusual' customer behaviour.”
No published response from this organisation was found for the earlier report.
This report (2025)
“I am concerned that as long as”
What was promised after the earlier report
“The final concern raised relates to ligature points in cells. HMPPS is currently undertaking a review of ligature-resistant cells, which have been designed to eliminate ligature points as far as possible.”
Wyndham Thomas: Prevention of future deaths report (2023)
“There is no mandatory requirement for a HMP Prison to have access to a Safer Cell (one with reduced ligature points).”
This report (2025)
“as long as "safer cells" are not made available away from the segregation unit at the HMP Hewell, an important measure for reducing the risk of suicide or self-harm is being withheld from vulnerable prisoners at that prison.”
What was promised after the earlier report
“We recognise that prisoners may feel vulnerable during their time in custody and HMPPS uses the Assessment, Care in Custody, Teamwork (ACCT) case management approach to support people at risk of self-harm and suicide. As part of any case review, those present will consider a range of measures to mitigate risk, including the prisoner's location and whether any possessions need to be removed or returned, and this may include moving the prisoner to a cell that is more appropriate to manage their risk”
This report (2025)
“newly qualified drivers may carry multiple peer-age passengers immediately after passing their test.”
Charlie Hopkins and William Robinson: Prevention of future deaths report (2024)
“As set out above, the court found that it was possible that the fact that [the deceased] had only just passed his driving test contributed to the collision.”
This report (2025)
“The inquest noted that newly qualified drivers may carry multiple peer-age passengers immediately after passing their test.”
What was promised after the earlier report
“We will be considering policies relating to young, new drivers during this development.”
Wilfred Fitchett, Jevon Hirst, Hugo Morris and Harvey Owen: Prevention of Future Deaths Report (2024)
“Currently, there are no legal restrictions upon the licences of young and/or newly qualified drivers and the current vehicle licensing regime permits the carrying of young persons as passengers in circumstances such as these.”
This report (2025)
“newly qualified drivers may carry multiple peer-age passengers immediately after passing their test.”
What was promised after the earlier report
“My Department is developing our road safety strategy and will set out more details in due course.”
Joseph Walsh: Prevention of Future Deaths Report (2025)
“Currently there are no legal restrictions upon the licences of young and /or newly qualified drivers and the current vehicle licensing regime permits the carrying of young persons as passengers in circumstances such as these.”
This report (2025)
“newly qualified drivers may carry multiple peer-age passengers immediately after passing their test.”
Tobias Barraclough: Prevention of Future Deaths Report (2025)
“Currently there are no legal restrictions upon the licences of young and /or newly qualified drivers and the current vehicle licensing regime permits the carrying of young persons as passengers in circumstances such as these”
This report (2025)
“newly qualified drivers may carry multiple peer-age passengers immediately after passing their test”
What was promised after the earlier report
“we are exploring options to tackle the root causes of this without unfairly penalising young drivers”
William Radford: Prevention of Future Deaths Report (2025)
“where an inexperienced driver has a distraction of another young person in the car this can increase their risk of having an accident.”
This report (2025)
“newly qualified drivers may carry multiple peer-age passengers immediately after passing their test.”
What was promised after the earlier report
“my Department is developing the first road safety strategy in over a decade and will set out more details in due course.”
This report (2025)
“The availability of illicit substances continued to be a serious concern that undermined safety and stability. The rate of positive drug tests remained as high as at our full inspection in 2023”
What was promised after the earlier report
“G4S does agree with Mr [name redacted] that HMP Birmingham would benefit from CCTV and airport style scanners. It is G4S's understanding that Mr [name redacted] submitted to HMPPS a case for funding in respect of the cost of purchase and installation of CCTV and that this has been approved. The CCTV will therefore be installed at HMP Birmingham in due course.”
Andrew Carr (2019)
“Many problems within the prison related to substances misuse are contributed to by the use of contraband mobile phones. The inquest heard evidence that blocking the use of mobile phones in prison would be very useful in mitigating this risk”
This report (2025)
“Mobile phones are easily available in HM Prison High Down, as in many other prisons in England & Wales a. The access to mobile phones facilitates prisoners' conduct and finance of drug dealing, including the arranging for the delivery of drugs by drones to precise locations at specified times”
No published response from this organisation was found for the earlier report.
Luke Jones (2019)
“The report of the Prisons and Probation Ombudsman highlighted that there were concerns regarding the accessibility of drugs within HMP Berwyn and notwithstanding that certain measures had been taken”
This report (2025)
“(1) New psychoactive substances, especially [REDACTED] , are easily available in HM Prison High Down, as in many other prisons in England & Wales”
Kristopher Tilbury: Prevention of future deaths report (2023)
“The Head of Safety advised that drugs are broughts into HMP The Mount by a number of ways:”
This report (2025)
“The availability and use of illicit drugs posed a threat to the stability of the prison, contributing to debt, bullying and fear. The positive drug testing rate at HMP High Down was among the highest in adult male prisons”
No published response from this organisation was found for the earlier report.
This report (2025)
“Prison Officer B ([REDACTED]) told the court: "[REDACTED] is a daily occurrence, it's too much to handle...some batches are bad and they can then be violent"”
No published response from this organisation was found for the earlier report.