101 Prevention of Future Deaths reports from the Avon coroner area, 2013–2026. Each one is a coroner's formal warning that something could cause more deaths unless it changes. Full text of every report is on this site.
70 of 101 (69%) have at least one response published on judiciary.uk.
This counts responses published against the report by anyone, not whether a particular body replied. Publication is at the Chief Coroner's discretion and was far less consistent in the corpus's early years, so read a low figure as a prompt to open the reports, not as a finding.
| Date | Report | Coroner | Category | Responses |
|---|---|---|---|---|
| 2026 | Clare Dupree | M Vision | State Custody related deaths | 1 |
| 2025 | Amy Cross | Peter Harrowing | Alcohol, drug and medication related deaths, Community health care and emergency services related deaths | 1 |
| 2025 | Mabel Williams | Robert Sowersby | Child Death (from 2015) | 1 |
| 2025 | Mabel Williams | Robert Sowersby | Child Death (from 2015) | 1 |
| 2025 | Melissa Mathieson | Maria Voisin | Care Home Health related deaths | 1 |
| 2025 | David Gifford | Debbie Rookes | Emergency services related deaths (2019 onwards) | 1 |
| 2025 | Sarah Lewis | Debbie Rookes | Suicide (from 2015), Alcohol, drug and medication related deaths | 2 |
| 2025 | Amy Levy | Robert Sowersby | Police related deaths, Emergency services related deaths (2019 onwards) | 3 |
| 2024 | Kayleigh Melhuish | Maria Voisin | State Custody related deaths, Suicide (from 2015) | 3 |
| 2024 | Lisa Gale | Simon Fox | Hospital Death (Clinical Procedures and medical management) related deaths | 4 |
| 2024 | Joseph Parker | Maria Voisin | Hospital Death (Clinical Procedures and medical management) related deaths | 3 |
| 2024 | Abdul Oryakhel | Maria Voisin | Other related deaths, Product related deaths | 3 |
| 2024 | Harry Vass | Maria Voisin | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2024 | Romeo Esposito | Simon Fox | Emergency services related deaths (2019 onwards), Child Death (from 2015) | 1 |
| 2024 | Gillian Baumgardt | Simon Fox | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2024 | Andrew Rees | Myfanwy Buckeridge | Other related deaths | 2 |
| 2023 | Gerald Cruse | Debbie Rookes | Emergency services related deaths (2019 onwards) | 1 |
| 2023 | Calogero Di Blasi | Debbie Rookes | Hospital Death (Clinical Procedures and medical management) related deaths | 2 |
| 2023 | Madeleine Lawrence | Peter Harrowing | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2023 | Stephen Cassidy | Simon Fox | Alcohol, drugs medication related deaths, Care Home Health related deaths | 2 |
| 2023 | Cherry Garland | Robert Sowersby | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2023 | Alan Nippard | Maria Voisin | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2023 | Clinton Fear | Simon Fox | Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2023 | Karl Mitchell | Peter Harrowing | Accident at Work and Health and Safety related deaths, Other related deaths | 1 |
| 2023 | Christopher Evans | Peter Harrowing | Other related deaths | |
| 2023 | Elizabeth Hutchins | Maria Voisin | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2022 | Celia Marsh | Maria Voisin | Other related deaths | 8 |
| 2022 | George Elliott | Robert Sowersby | Other related deaths | 1 |
| 2022 | Gerwyn Rees | Robert Sowersby | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2022 | Donald Gore | Simon Fox | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2022 | Susan Carling | Maria Voisin | Suicide (from 2015), Mental Health related deaths | 2 |
| 2022 | Reginald Weston | Myfanwy Buckeridge | Care Home Health related deaths | 1 |
| 2022 | Ami Mitchell | Simon Fox | Suicide (from 2015) | 1 |
| 2021 | Maria Stancliffe-Cook | Maria Voisin | Mental Health related deaths, Hospital Death (Clinical Procedures and medical management) related deaths | 2 |
| 2021 | Anastasia Uglow | Maria Voisin | Other related deaths, Child Death (from 2015) | 1 |
| 2021 | Jerome Peat | Dr Simon Fox Qc | Community health care, Alcohol, drug and medication related deaths | |
| 2020 | Lesley Brass | Robert Sowersby | Hospital Death (Clinical Procedures and medical management) related deaths, Other related deaths | |
| 2020 | Julie O’Connor | Maria Voisin | Community health care | 1 |
| 2019 | Alice Sloman | Simon Fox Qc | Child Death (from 2015), Community health care (Including primary care, GP) related deaths | 2 |
| 2019 | Shaun Dewey | Maria Voisin | Suicide (from 2015), State Custody related deaths | 1 |
| 2019 | Antonis Hannides | Simon Fox | Hospital Death (Clinical Procedures and medical management) related deaths | 2 |
| 2019 | Abdeslam Benelghazi | Maria Voisin | Alcohol, drug and medication related deaths, Mental Health related deaths | 1 |
| 2019 | Benjamin Murray | Maria Voisin | Suicide (from 2015) | 3 |
| 2019 | Natasha Abrahart | Maria Voisin | Mental Health related deaths, Suicide (from 2015) | 3 |
| 2019 | Alexander Green | Maria Voisin | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2019 | Marcie Tadman | Maria Voisin | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2019 | Evie Wright | Maria Voisin | Other related deaths | 2 |
| 2019 | Elizabeth Curtis | Maria Voisin | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2019 | Christopher Seal | Maria Voisin | Community health care, Mental Health related deaths | 1 |
| 2018 | Susan Longden | Peter Harrowing | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2018 | Bertram Crawford | Maria Voisin | Other related deaths | 1 |
| 2018 | Annette Hill | Terence Moore | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2018 | Henry Miller | Maria Voisin | Other related deaths | 1 |
| 2018 | Jacqueline Jordan | Maria Voisin | Road (Highways Safety) related deaths | 1 |
| 2018 | Graham Fox | Robert Sowersby | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2018 | Michalla Sweeting | Maria Voisin | Community health care and emergency services related deaths, State Custody related deaths | |
| 2018 | Yazin Elhjaje | Maria Voisin | Hospital Death (Clinical Procedures and medical management) related deaths, Child Death (from 2015) | |
| 2018 | John Wherlock | Robert Sowersby | Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2018 | Sandra Miller | Peter Harrowing | Care Home Health related deaths | |
| 2017 | Rebecca Romero | Maria Voisin | Child Death (from 2015), Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2017 | Irene Baker | Simon Fox | Care Home Health related deaths | 1 |
| 2017 | Shaun Berryman | Simon Fox | Community health care and emergency services related deaths | 1 |
| 2017 | Jonathan Shaw | Maria Voisin | Road (Highways Safety) related deaths | |
| 2017 | Terence Davies | Terence Moore | Road (Highways Safety) related deaths | |
| 2017 | Callum Smith | Maria Voisin | Community health care and emergency services related deaths, Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2017 | Rayan Ahmed | Maria Voisin | Child Death (from 2015), Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2017 | David Birtwistle | Terence Moore | Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2017 | Isabel Gentry | Maria Voison | Hospital Death (Clinical Procedures and medical management) related deaths, Child Death (from 2015) | |
| 2017 | Margaret Jones | Peter Harrowing | Road (Highways Safety) related deaths | 1 |
| 2016 | Martyn Watkins | Dr Peter Harrowing | Suicide (from 2015), Mental Health related deaths | 1 |
| 2016 | John Jones | Robert Sowersby | Mental Health related deaths | |
| 2016 | Oliver Ford | Maria Voisin | Mental Health related deaths | 1 |
| 2016 | Rohan Fitzsimons | Peter Harrowing | Community health care and emergency services related deaths | 1 |
| 2016 | Stephanie Marks | S Fox Qc | Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2016 | Joseph Sarkozi | Peter Horrowing | Community health care and emergency services related deaths | 1 |
| 2016 | Terence Brooks | Peter Harrowing | Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2016 | Marilyn Anson | Peter Harrowing | Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2015 | George Hines | Peter Harrowing | Other related deaths | |
| 2015 | Charlotte Bevan and Zaani Malbrouck | Maria Voisin | Child Death (from 2015), Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2015 | Scarlett Jukes | Peter Harrowing | Other related deaths | 1 |
| 2015 | Simon Reynolds | Maria Voisin | Mental Health related deaths | |
| 2015 | Masoud Ghaderi | Peter Harrowing | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2015 | Alison Draper | Maria Voisin | Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2015 | Michael Hacker | Maria Voisin | Community health care and emergency services related deaths | |
| 2015 | Kimberley Parsons | Peter Harrowing | Suicide (from 2015) | 2 |
| 2015 | Christopher Taylor | Maria Voisin | Community health care and emergency services related deaths | 2 |
| 2015 | Sian Armstrong | Maria Voisin | Hospital Death (Clinical Procedures and medical management) related deaths, Child Death (from 2015) | |
| 2014 | Peter Dorney | Maria Voisin | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2014 | Elsie Plumb | Maria Voisin | Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2014 | Gerardo Tonogbanua | Maria Voisin | Other related deaths | |
| 2014 | Dafydd Watts | T G Moore | Alcohol, drug and medication related deaths | |
| 2014 | Robert Perkins | Peter Harrowing | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2014 | Yasmin Richards | Peter Harrowing | Road (Highways Safety) related deaths | 1 |
| 2014 | Scarlett Sinclair | Maria Voisin | Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2014 | Chloe Grace Flavell | Maria Voisin | Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2013 | Felix Cembrowicz | Terence Moore | Mental Health related deaths | 1 |
| 2013 | Alan Stanfield Browning | Simon Fox | Alcohol, drug and medication related deaths | |
| 2013 | Garrett Joseph Franklin Elsey | Terence G Moore | Other related deaths | |
| 2013 | Rose Jean Coles | Maria Voisin | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2013 | Jared William McDowall | Maria Voisin | Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2013 | Ann Margaret Spearing | T G Moore | Community health care and emergency services related deaths | 1 |
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