Coroner reports

Articles in this category

1. Prevention of future deaths report: Pamela Honeybone (25 September 2025)

   • Patient death
   • Coroner
   • (and 9 more)

     Tagged with:

     • Patient death
     • Coroner
     • Accident and Emergency
     • Tests / investigations
     • Radiology
     • Diagnostic error
     • Checklists
     • Patient identification
     • Cancer
     • Coroner reports
     • UK

   By Anonymous, 3 June

   • 0 comments
   • 137 views
   • 
   • Added by Anonymous
   • 3 June

2. Coroners statistics 2025: England and Wales

   • Coroner reports
   • Patient death
   • (and 1 more)

     Tagged with:

     • Coroner reports
     • Patient death
     • Data

   By Patient Safety Learning, 28 May

   • 0 comments
   • 255 views
   • 
   • Added by Patient Safety Learning
   • 28 May

3. Browne Jacobson: Guide to preparing and delivering evidence of organisational learning to the Coroner (15 November 2023)

   • Coroner
   • Investigation
   • (and 4 more)

     Tagged with:

     • Coroner
     • Investigation
     • Legal issue
     • Staff support
     • Coroner reports
     • Organisational learning

   By Patient Safety Learning, 12 May

   • 0 comments
   • 121 views
   • 
   • Added by Patient Safety Learning
   • 12 May

4. The impact of the Patient Safety Incident Response Framework (PSIRF) on preparing for inquests: Navigating the evidential gap (7 May 2026)

   • Coroner reports
   • Investigation
   • (and 1 more)

     Tagged with:

     • Coroner reports
     • Investigation
     • PSIRF

   By Patient Safety Learning, 8 May

   • 0 comments
   • 325 views
   • 
   • Added by Patient Safety Learning
   • 8 May

5. Prevention of future deaths report: Roman Barr (3 April 2026)

   • Coroner
   • Coroner reports
   • (and 6 more)

     Tagged with:

     • Coroner
     • Coroner reports
     • Patient death
     • Asthma
     • Emergency medicine
     • Recommendations
     • Handover
     • Communication problems

   By Patient Safety Learning, 17 April

   • 0 comments
   • 234 views
   • 
   • Added by Patient Safety Learning
   • 17 April

6. Prevention of Future Deaths Report: Aarav Chopra (13 January 2025)

   • Coroner reports
   • Coroner
   • (and 6 more)

     Tagged with:

     • Coroner reports
     • Coroner
     • Patient death
     • Skill-based issue
     • Medication
     • Communication problems
     • Training
     • Risk assessment

   By Patient Safety Learning, 23 March

   • 0 comments
   • 259 views
   • 
   • Added by Patient Safety Learning
   • 23 March

7. Prevention of Future Death report: Terrence Frost (12 March 2026)

   • Coroner
   • Coroner reports
   • (and 6 more)

     Tagged with:

     • Coroner
     • Coroner reports
     • Sepsis
     • Patient death
     • Communication problems
     • GP
     • Accident and Emergency
     • Diagnosis

   By Patient Safety Learning, 16 March

   • 0 comments
   • 251 views
   • 
   • Added by Patient Safety Learning
   • 16 March

8. A network and thematic analysis of mental health-related Prevention of Future Death reports from 2013 to 2025 in England and Wales (5 February 2026)

   • Coroner reports
   • Mental health
   • (and 1 more)

     Tagged with:

     • Coroner reports
     • Mental health
     • Research

   By Patient Safety Learning, 12 February

   • 0 comments
   • 473 views
   • 
   • Added by Patient Safety Learning
   • 12 February

9. Prevention of future deaths report: Avery Hall (2 February 2026)

   • Patient death
   • Baby
   • (and 7 more)

     Tagged with:

     • Patient death
     • Baby
     • Pregnancy
     • Medication
     • Adverse reaction
     • Investigation
     • Coroner
     • Coroner reports
     • Communication problems

   By Patient Safety Learning, 5 February

   • 0 comments
   • 660 views
   • 
   • Added by Patient Safety Learning
   • 5 February

10. Prevention of Future Deaths Report: Matilda Pomfret-Thomas (21 January 2026 )

    • Coroner
    • Coroner reports
    • (and 7 more)

      Tagged with:

      • Coroner
      • Coroner reports
      • Maternity
      • Pregnancy
      • Midwife
      • Patient death
      • Baby
      • Skill-based issue
      • Regulatory issue

    By Patient Safety Learning, 22 January

    • 0 comments
    • 486 views
    • 
    • Added by Patient Safety Learning
    • 22 January

11. Prevention of future deaths report: Jennifer Cahill and Agnes Cahill (7 November 2025)

    • Coroner reports
    • Coroner
    • (and 10 more)

      Tagged with:

      • Coroner reports
      • Coroner
      • Midwife
      • Maternity
      • Pregnancy
      • Labour
      • Patient death
      • Baby
      • Skills
      • Organisation / service factors
      • Risk assessment
      • Risk management

    By Patient Safety Learning, 20 January

    • 0 comments
    • 1,644 views
    • 
    • Added by Patient Safety Learning
    • 20 January

12. Prevention of future deaths report: Adam Hussain (8 January 2026)

    • Coroner reports
    • Patient death
    • (and 2 more)

      Tagged with:

      • Coroner reports
      • Patient death
      • Accident and Emergency
      • Care coordination

    By Mark Hughes, 15 January

    • 0 comments
    • 425 views
    • 
    • Added by Mark Hughes
    • 15 January

13. Prevention of future deaths report: Mohamed Abdisamad (28 December 2025)

    • Coroner reports
    • Patient death
    • (and 1 more)

      Tagged with:

      • Coroner reports
      • Patient death
      • Baby

    By Patient_Safety_Learning, 5 January

    • 0 comments
    • 486 views
    • 
    • Added by Patient_Safety_Learning
    • 5 January

14. Prevention of Future Deaths report: Aviva Otte, Oscar Barker and Yousef Al-Kharboush (15 November 2024)

    • Baby
    • Medication
    • (and 6 more)

      Tagged with:

      • Baby
      • Medication
      • Parenteral nutrition
      • Patient death
      • Coroner
      • Coroner reports
      • Paediatrics
      • Recommendations

    By Patient Safety Learning, 3 January

    • 0 comments
    • 185 views
    • 
    • Added by Patient Safety Learning
    • 3 January

15. Prevention of future deaths report: John Rust (20 October 2025)

    • Coroner reports
    • Coroner
    • (and 5 more)

      Tagged with:

      • Coroner reports
      • Coroner
      • Investigation
      • Patient death
      • Medical device
      • Training
      • Skill-based issue

    By Patient Safety Learning, 28 October, 2025

    • 0 comments
    • 419 views
    • 
    • Added by Patient Safety Learning
    • 28 October, 2025

16. Prevention of Future Deaths Report: Keith Hankin (19 September 2025)

    • Patient death
    • Medicine - Neurology
    • (and 2 more)

      Tagged with:

      • Patient death
      • Medicine - Neurology
      • Private sector
      • Operating theatre / recovery

    By Mark Hughes, 14 October, 2025

    • 0 comments
    • 747 views
    • 
    • Added by Mark Hughes
    • 14 October, 2025

17. Prevent of Future Deaths report: Gareth Johnson (12 September 2025)

    • Coroner reports
    • Patient death
    • (and 3 more)

      Tagged with:

      • Coroner reports
      • Patient death
      • Coroner
      • Infrastructure / building / equipment
      • Investigation

    By Patient Safety Learning, 29 September, 2025

    • 0 comments
    • 407 views
    • 
    • Added by Patient Safety Learning
    • 29 September, 2025

18. Prevention of Future Deaths report: Jessica Smithson (8 September 2025)

    • Collaboration
    • Care coordination
    • (and 8 more)

      Tagged with:

      • Collaboration
      • Care coordination
      • Mental health
      • Police
      • Self harm/ suicide
      • Patient death
      • Coroner
      • Coroner reports
      • Communication problems
      • Organisation / service factors

    By Patient Safety Learning, 8 September, 2025

    • 0 comments
    • 552 views
    • 
    • Added by Patient Safety Learning
    • 8 September, 2025

19. Prevention of Future Deaths Report: Daisy McCoy (6 August 2025)

    • Coroner
    • Coroner reports
    • (and 11 more)

      Tagged with:

      • Coroner
      • Coroner reports
      • Patient death
      • Investigation
      • Maternity
      • Baby
      • Pregnancy
      • Labour
      • Training
      • Communication problems
      • Information sharing
      • Organisational culture
      • Policies / Protocols / Procedures

    By Patient Safety Learning, 20 August, 2025

    • 0 comments
    • 330 views
    • 
    • Added by Patient Safety Learning
    • 20 August, 2025

20. Prevention of Future Deaths Report: John Kirkman (16 July 2025)

    • Coroner
    • Coroner reports
    • (and 7 more)

      Tagged with:

      • Coroner
      • Coroner reports
      • Information sharing
      • Assessment
      • Mental health
      • Self harm/ suicide
      • Schizophrenia
      • Patient death
      • Investigation

    By Patient Safety Learning, 22 July, 2025

    • 0 comments
    • 498 views
    • 
    • Added by Patient Safety Learning
    • 22 July, 2025

21. Prevention of Future Deaths Report: Thomas Mallinson (15 July 2025)

    • Care coordination
    • Patient death
    • (and 7 more)

      Tagged with:

      • Care coordination
      • Patient death
      • Organisation / service factors
      • Coroner
      • Coroner reports
      • Investigation
      • Emergency medicine
      • GP
      • Ambulance

    By Patient Safety Learning, 17 July, 2025

    • 0 comments
    • 377 views
    • 
    • Added by Patient Safety Learning
    • 17 July, 2025

22. Prevention of Future Deaths Report: Sophie Cotton (29 May 2025)

    • Coroner
    • Coroner reports
    • (and 5 more)

      Tagged with:

      • Coroner
      • Coroner reports
      • Mental health
      • Police
      • Patient death
      • Self harm/ suicide
      • Policies / Protocols / Procedures

    By Patient Safety Learning, 25 June, 2025

    • 0 comments
    • 630 views
    • 
    • Added by Patient Safety Learning
    • 25 June, 2025

23. Prevention of Future Deaths Report: Peter Anzani (19 May 2025)

    • Coroner
    • Coroner reports
    • (and 6 more)

      Tagged with:

      • Coroner
      • Coroner reports
      • Patient death
      • Care record
      • Training
      • Additional staff required
      • Funding
      • Workforce management

    By Patient Safety Learning, 22 May, 2025

    • 0 comments
    • 435 views
    • 
    • Added by Patient Safety Learning
    • 22 May, 2025

24. Prevention of Future Deaths Report: Lorraine Parker (24 April 2025)

    • Coroner
    • Coroner reports
    • (and 5 more)

      Tagged with:

      • Coroner
      • Coroner reports
      • Patient death
      • Organisational culture
      • Investigation
      • Surgeon
      • Diagnosis

    By Patient Safety Learning, 2 May, 2025

    • 0 comments
    • 737 views
    • 
    • Added by Patient Safety Learning
    • 2 May, 2025

25. Prevention of Future Deaths Report: Jacqueline Anne Potter (25 April 2025)

    • Patient death
    • Mental health
    • (and 3 more)

      Tagged with:

      • Patient death
      • Mental health
      • Menopause
      • Womens health
      • Primary care

    By Mark Hughes, 30 April, 2025

    • 0 comments
    • 997 views
    • 
    • Added by Mark Hughes
    • 30 April, 2025