139 Prevention of Future Deaths reports from the London Inner (South) 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.
117 of 139 (84%) 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 | Mark Smith | Jenny Goldring | State Custody related deaths | |
| 2026 | Lee Adams | Julian Morris | Mental Health related deaths | 1 |
| 2026 | Lee Adams | Julian Morris | Mental Health related deaths | 1 |
| 2026 | Simon Moss | Xavier Mooyaart | Suicide (from 2015) | 1 |
| 2025 | Sundeep Ghuman | David Manknell | State Custody related deaths | 1 |
| 2025 | Joan Talbot | Liliane Field | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2025 | Paula Doreen | Liliane Field | Alcohol, drug and medication related deaths, Hospital Death (Clinical Procedures and medical management) related deaths | 5 |
| 2025 | James Siddons | Liliane Field | Care Home Health related deaths | 2 |
| 2025 | Naomi Suleyman | Liliane Field | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2025 | Charlie Marriage | Xavier Mooyaart | Alcohol, drug and medication related deaths | 1 |
| 2024 | Edward Barnard | Christopher Williams | Suicide (from 2015), Alcohol, drug and medication related deaths | 1 |
| 2024 | Aviva Otte, Oscar Barker and Yousef Al-Kharboush | Julian Morris | Child Death (from 2015), Alcohol, drug and medication related deaths | 4 |
| 2024 | Lacey Brookman | Julian Morris | Child Death (from 2015), Hospital Death (Clinical Procedures and medical management) related deaths | 4 |
| 2024 | Kasey Beech | Xavier Mooyaart | Hospital Death (Clinical Procedures and medical management) related deaths | 3 |
| 2024 | Joshua Delaney | David Manknell | Alcohol, drug and medication related deaths | 1 |
| 2024 | Jacqueline Cobain | Michelle Haste | Railway related deaths, Suicide (from 2015) | 1 |
| 2024 | Isabella Shere | Fleur Hallett | Suicide (from 2015), Child Death (from 2015) | 2 |
| 2024 | Oliver Beswetherick | Julian Morris | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2023 | Jonathan Goldstein, Hannah Goldstein and Saskia Goldstein | David Manknell | Other related deaths, Child Death (from 2015) | 1 |
| 2023 | Fraser Moore | Julian Morris | Railway related deaths | |
| 2023 | Manoel Santos | Jenny Goldring | State Custody related deaths, Suicide (from 2015) | 3 |
| 2023 | Isabela Suciu | Andrew Harris | Child Death (from 2015), Hospital Death (Clinical Procedures and medical management) related deaths | 2 |
| 2023 | Juanita Nti | Andrew Harris | Child Death (from 2015) | 1 |
| 2023 | Shirley Ashelford | Christopher Williams | Other related deaths | 1 |
| 2023 | Stephen Weatherley | Jenny Goldring | Alcohol, drug and medication related deaths, State Custody related deaths | 4 |
| 2023 | Christian Tuvi | Andrew Harris | Other related deaths | 2 |
| 2023 | Tomas Ceida | Andrew Harris | Other related deaths | 2 |
| 2023 | Nathan Forrester | Andrew Harris | Alcohol, drug and medication related deaths, State Custody related deaths | 2 |
| 2022 | Liridon Saliuka | Philip Barlow | State Custody related deaths, Suicide (from 2015) | 2 |
| 2022 | Daniel O’Sullivan | Christopher Williams | Suicide (from 2015), Alcohol, drug and medication related deaths | 2 |
| 2022 | Katie Horne | Andrew Harris | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2022 | Locksley Burton | Andrew Harris | Care Home Health related deaths, Other related deaths | 3 |
| 2022 | Louise Bailey | Jonathan Landau | Road (Highways Safety) related deaths, Police related deaths | 2 |
| 2022 | Ian Taylor | Andrew Harris | Police related deaths | 4 |
| 2021 | Mark Castley | Andrew Harris | Suicide (from 2015), Other related deaths | 2 |
| 2021 | Katrina Makunova | Andrew Harris | Police related deaths, Other related deaths | 1 |
| 2021 | Stephen Cope | Dr Julian Morris | State Custody related deaths, Mental Health related deaths | 2 |
| 2021 | Emma Day | Andrew Harris | Police related deaths, Other related deaths | 1 |
| 2021 | Abiodun Oritogun | Andrew Harris | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2021 | Ella Kissi-Debrah | Philip Barlow | Child Death (from 2015), Community health care | 12 |
| 2021 | Yusuf Seyit | Andrew Harris | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2021 | Joseph Agnew | Andrew Harris | Alcohol, drug and medication related deaths, Police related deaths | 3 |
| 2021 | Kevin Clarke | Andrew Harris | Police related deaths, Emergency services related deaths (2019 onwards) | 2 |
| 2021 | Jason O’Rourke | Henrietta Hill Qc | State Custody related deaths, Mental Health related deaths | 1 |
| 2020 | Ruben Bousquet | Andrew Harris | Product related deaths, Other related deaths | 3 |
| 2020 | Claire Lilley | Dr Julian Morris | Hospital Death (Clinical Procedures and medical management) related deaths, Mental Health related deaths | 1 |
| 2020 | Gary Etherington | Andrew Harris | Mental Health related deaths, Community health care | 1 |
| 2020 | Omarian Brooks | Andrew Harris | Community health care | 3 |
| 2020 | Kerry Aldridge | Andrew Harris | Railway related deaths, Suicide (from 2015) | 1 |
| 2020 | Adrian Ashford | Andrew Harris | Hospital Death (Clinical Procedures and medical management) related deaths, Mental Health related deaths | 1 |
| 2019 | London Bridge & Borough Market Terror Attack | Hhj Mark Lucraft Qc | Other related deaths | 5 |
| 2019 | Derek Weaver | Andrew Harris | Hospital Death (Clinical Procedures and medical management) related deaths | 3 |
| 2019 | Alex Malcolm | Andrew Harris | Child Death (from 2015) | 1 |
| 2019 | Owen Carey | Briony Ballard | Other related deaths, Product related deaths | 4 |
| 2019 | Rebecca Marshall | Briony Ballard | Hospital Death (Clinical Procedures and medical management) related deaths, Suicide (from 2015) | 1 |
| 2019 | Daniel Williams | Briony Ballard | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2019 | Francis Hodge | Briony Ballard | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2019 | Alex Blake | Andrew Harris | Alcohol, drug and medication related deaths, Hospital Death (Clinical Procedures and medical management) related deaths | 2 |
| 2019 | Annabel Newport | Henrietta Hill Qc | Other related deaths | 2 |
| 2019 | Feni Lee | Philip Barlow | Community health care | 1 |
| 2019 | Robert Cobbina | Xavier Mooyaart | Emergency services related deaths (2019 onwards) | 1 |
| 2019 | Edward Hearn | Andrew Harris | Hospital Death (Clinical Procedures and medical management) related deaths | 3 |
| 2019 | Bernard O’Flynn | Christopher Williams | State Custody related deaths | |
| 2019 | Royston Kemp | Andrew Harris | Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2019 | Julia Peto | Christopher Williams | Road (Highways Safety) related deaths | 1 |
| 2019 | Donna Williamson | Andrew Harris | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2019 | Gabriele Kreichgauer | Philip Barlow | Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2018 | Paul Fairey | Philip Barlow | Road (Highways Safety) related deaths | 1 |
| 2018 | REDACTED | Henrietta Hill Qc | Community health care, Suicide (from 2015) | 1 |
| 2018 | Thomas McAuley | Andrew Harris | State Custody related deaths | 1 |
| 2018 | Nigel Handscomb | Philip Barlow | Community health care and emergency services related deaths | |
| 2018 | Yunis Hadi | Lorna Tagliavini | Other related deaths, Child Death (from 2015) | 1 |
| 2018 | Edward Joyce | Philip Barlow | Hospital Death (Clinical Procedures and medical management) related deaths, Child Death (from 2015) | 1 |
| 2018 | William Dickens | Henrietta Hill Qc | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2018 | Katy Roberts | Lorna Tagliavini | Hospital Death (Clinical Procedures and medical management) related deaths, Child Death (from 2015) | 1 |
| 2018 | Rastislav Petrisko | Andrew Harris | Mental Health related deaths | |
| 2018 | Michael Vukovic | Philip Barlow | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2018 | Abdul-Jamal Ottun | Andrew Harris | Other related deaths | 1 |
| 2017 | Anne Morris | Christopher Williams | Hospital Death (Clinical Procedures and medical management) related deaths | 2 |
| 2017 | Harold Chapman | Julian Morris | Hospital Death (Clinical Procedures and medical management) related deaths | 3 |
| 2017 | Peter Kollar | Andrew Harris | Hospital Death (Clinical Procedures and medical management) related deaths, Child Death (from 2015) | 1 |
| 2017 | Hannah Barney | Andrew Harris | Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2017 | Constance Connolly | Andrew Harris | Hospital Death (Clinical Procedures and medical management) related deaths | 2 |
| 2017 | Maurice Macdonnell | Andrew Harris | Product related deaths | 1 |
| 2017 | Jamie Pashley | Julian Morris | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2017 | Cedric Skyers | Andrew Harris | Other related deaths | 3 |
| 2017 | James O’Brien | Philip Barlow | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2017 | Alan Walsh | Andrew Harris | Accident at Work and Health and Safety related deaths | |
| 2017 | Esther Hartsilver | Sarah Ormond Walshe | Road (Highways Safety) related deaths | 2 |
| 2017 | Robert Entenman | Henrietta Hill Qc | Hospital Death (Clinical Procedures and medical management) related deaths | 3 |
| 2016 | Edwin Flett | Andrew Harris | Other related deaths | |
| 2016 | Richard Walsh | Andrew Harris | State Custody related deaths, Suicide (from 2015) | 4 |
| 2016 | Debrata Sircar | Dr Andrew Harris | Hospital Death (Clinical Procedures and medical management) related deaths, Mental Health related deaths | 1 |
| 2016 | Daphne McCorkle | Henrietta Hill Qc | Community health care and emergency services related deaths | 1 |
| 2016 | Amanda Coppen | Philip Barlow | Road (Highways Safety) related deaths | 1 |
| 2016 | Rosemarie Dees | Henrietta Hills Qc | Product related deaths | |
| 2016 | Richard Hinchliffe | Philip Barlow | Alcohol, drug and medication related deaths, Railway related deaths | |
| 2016 | Christina O’Brien | Christopher Williams | Mental Health related deaths, Suicide (from 2015) | |
| 2016 | Edward Paddon-Bramley | Julian Morris | Hospital Death (Clinical Procedures and medical management) related deaths, Child Death (from 2015) | 2 |
| 2016 | Christ Morrison | Andrew Harris | Child Death (from 2015), Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2016 | Jakovas Fofonovas | Andrew Harris | Railway related deaths | 1 |
| 2016 | Matthew Wood | Andrew Harris | Other related deaths | 2 |
| 2015 | Rosina Drury | Andrew Harris | Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2015 | Lee Bates | Andrew Harris | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2015 | Wiktoria Was | Tony Badenoch | Police related deaths, Road (Highways Safety) related deaths | 1 |
| 2015 | Michael George | Andrew Harris | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2015 | Matthew Hoare | Lorna Tagliavini | Railway related deaths | 1 |
| 2015 | Laurence Boyens | Andrew Harris | State Custody related deaths | 2 |
| 2015 | Archie Hexall | Philip Barlow | Child Death (from 2015), Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2015 | Maria Nekrasova | Paul Matthews | Road (Highways Safety) related deaths | 1 |
| 2015 | Max Carlton-Smith | Andrew Harris | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2014 | Moses McDonald | Lorna Tagliavini | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2014 | Sandra Higham | Henrietta Hill | Hospital Death (Clinical Procedures and medical management) related deaths | 3 |
| 2014 | Christopher Ajayi | Sarah Ormond Walshe | Community health care and emergency services related deaths, Hospital Death (Clinical Procedures and medical management) related deaths | 2 |
| 2014 | Philip Allen | Philip Barlow | Community health care and emergency services related deaths | 1 |
| 2014 | Samuel Duckworth | Andrew Harris | Alcohol, drug and medication related deaths | 1 |
| 2014 | Yaser Saleh | Andrew Harris | Community health care and emergency services related deaths | |
| 2014 | Arsema Dawit | Andrew Harris | Police related deaths | 1 |
| 2014 | Aaron Plowman | Lorna Tagliavini | Railway related deaths | |
| 2014 | Lauren Barfoot | Lorna Tagliavini | Other related deaths | 4 |
| 2014 | Thomas Warren | Andrew Harris | Hospital Death (Clinical Procedures and medical management) related deaths | 2 |
| 2014 | Vijay Sonagara | Philip Barlow | Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2014 | Sadik Miah | Andrew Harris | Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2014 | Gary Richards | Andrew Harris | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2014 | Abiola Dosunmu | Andrew Walker | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2014 | Akua Anokye-Boateng | Andrew Harris | Alcohol, drug and medication related deaths | 1 |
| 2014 | Lisa Webb | Andrew Harris | Community health care and emergency services related deaths | 1 |
| 2014 | Jennifer Tompkins | Philip Barlow | Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2014 | Michael Anthony | Andrew Harris | Community health care and emergency services related deaths | 1 |
| 2014 | Teresa Lonergan | Andrew Harris | Community health care and emergency services related deaths | |
| 2014 | Kirabo Kiwanuka | Andrew Harris | Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2014 | Rachel Burke | Andrew Harris | Other related deaths | 1 |
| 2014 | Arthur Brockett-Deakins | Andrew Harris | Hospital Death (Clinical Procedures and medical management) related deaths | 4 |
| 2013 | Adrian Johnson | Andrew Harris | State Custody related deaths | 1 |
| 2013 | Leo Deady | Phillip Barlow | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2013 | Jacqueline Allwood | Andrew Harris | Community health care, Emergency Services related deaths | 1 |
| 2013 | Amna Umer Ahmed | Andrew Harris | Community Healthcare Death | 1 |
| 2013 | Luna Lesko | Andrew Harris | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2013 | Mohammed Chaudhury | Andrew Harris | Hospital Death (Clinical Procedures and medical management) related deaths |
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