181 Prevention of Future Deaths reports categorised Community health care, 2013–2022. 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.
128 of 181 (71%) 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 |
|---|---|---|---|---|
| 2022 | Lilian Behrendt | Jacqueline Lake | Care Home Health related deaths, Emergency services related deaths (2019 onwards) | 1 |
| 2022 | Matthew Evans | Karen Henderson | Community health care, Mental Health related deaths | 6 |
| 2022 | Sarah Dunn | Louise Rae | Hospital Death (Clinical Procedures and medical management) related deaths, Community health care | 1 |
| 2022 | Susan Carling | Maria Voisin | Suicide (from 2015), Mental Health related deaths | 2 |
| 2022 | Volodymyr Korol | Anna Crawford | Mental Health related deaths, Community health care | |
| 2022 | Ryan Merna | Richard Middleton | Other related deaths, Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2022 | Natalie Turner | Alan Wilson | Alcohol, drug and medication related deaths, Other related deaths | 2 |
| 2022 | Donald Compton | Dr Sarah Jane Richards | Wales prevention of future deaths reports (2019 onwards), Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2022 | Jane Allison | Crispin Oliver | Community health care, Alcohol, drug and medication related deaths | 4 |
| 2022 | Michael Humphries | Jessica Russell Mitra | Care Home Health related deaths, Community health care | |
| 2022 | Jack Ritchie | David Urpeth | Suicide (from 2015), Community health care | |
| 2022 | Brian Wareham | Caroline Saunders | Wales prevention of future deaths reports (2019 onwards), Community health care | 2 |
| 2022 | James Emmerson | Sean Cummings | Mental Health related deaths, Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2021 | Sameena Javed | Catherine Mckenna | Community health care | |
| 2021 | Louise Cooper | Alan Wilson | Community health care, Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2021 | Maria McGauran | Sabyta Kaushal | Alcohol, drug and medication related deaths, Community health care | 1 |
| 2021 | Darrell Devlin | Dr Nicholas Shaw | Alcohol, drug and medication related deaths, Product related deaths | 2 |
| 2021 | Michelle Jeffries | Christopher Morris | Alcohol, drug and medication related deaths, Community health care | 2 |
| 2021 | Emma Burbury | Andrew Cox | Mental Health related deaths, Community health care | 2 |
| 2021 | Ethel Beaumont | Lorna Skinner Qc | Hospital Death (Clinical Procedures and medical management) related deaths, Community health care | |
| 2021 | Katrina Makunova | Andrew Harris | Police related deaths, Other related deaths | 1 |
| 2021 | Jane Bruce | Professor Catherine Mason | Hospital Death (Clinical Procedures and medical management) related deaths, Community health care | |
| 2021 | Henry Doll | Anna Crawford | Care Home Health related deaths, Community health care | |
| 2021 | Helena Opuku | Graeme Irvine | Community health care, Other related deaths | |
| 2021 | Charlotte Duffield | Dr Nicholas Shaw | Other related deaths, Community health care | 1 |
| 2021 | Siwan Smith | Caroline Saunders | Community health care, Mental Health related deaths | 1 |
| 2021 | Billy Warwick-Jones | Lydia Brown | Road (Highways Safety) related deaths, Community health care | 2 |
| 2021 | Barry Martin | Christopher Murray | Community health care, Other related deaths | 1 |
| 2021 | Maureen Johnson | Chris Morris | Community health care | 1 |
| 2021 | Bituin Pimlott | Alison Mutch | Community health care, Suicide (from 2015) | 2 |
| 2021 | Norma Rushworth | Alison Mutch | Hospital Death (Clinical Procedures and medical management) related deaths, Community health care | 2 |
| 2021 | Stanislaw Zielinski | Alison Mutch | Mental Health related deaths, Community health care | 3 |
| 2021 | Anita Mandalia | Graeme Irvine | Community health care, Alcohol, drug and medication related deaths | |
| 2021 | Samantha Singh | Graeme Irvine | Community health care, Other related deaths | |
| 2021 | Henry Boddy | Richard Brittain | Community health care, Other related deaths | 1 |
| 2021 | Joan Prescott | Ian Arrow | Other related deaths, Community health care | |
| 2021 | Fiona Humberstone | Sean Horstead | Hospital Death (Clinical Procedures and medical management) related deaths, Community health care | |
| 2021 | Heather Page | Gordon Clow | Mental Health related deaths, Railway related deaths | 5 |
| 2021 | Netlyn Robinson | Lorraine Harris | Community health care, Other related deaths | 1 |
| 2021 | Hazel Binks | Peter Nieto | Community health care, Suicide (from 2015) | |
| 2021 | Judith Varley | Mary Burke | Community health care | 1 |
| 2021 | Rodney Dixon | James Healy Pratt | Hospital Death (Clinical Procedures and medical management) related deaths, Mental Health related deaths | 2 |
| 2021 | 2021-0205 | Emma Serrano | Community health care, Other related deaths | 1 |
| 2021 | Ian Hall | Alison Mutch | Community health care, Other related deaths | 1 |
| 2021 | Brian Mottram | Alison Mutch | Community health care | 1 |
| 2021 | Clive Rivers | Alison Mutch | Hospital Death (Clinical Procedures and medical management) related deaths, Community health care | 2 |
| 2021 | Marc Bennett | Ian Arrow | Community health care, Mental Health related deaths | |
| 2021 | Darrell Spear | Alison Mutch | Community health care, Other related deaths | |
| 2021 | Pathushan Sutharsan | Penelope Schofield | Road (Highways Safety) related deaths, Community health care | 1 |
| 2021 | Angela Best | Mary Hassell | Community health care, Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2021 | Steven Allen | Alison Mutch | Community health care, Alcohol, drug and medication related deaths | 1 |
| 2021 | Samantha Gould | Nicholas Moss Qc | Child Death (from 2015), Suicide (from 2015) | 4 |
| 2021 | Kevin Fitton | Veronica Hamilton Deeley | Hospital Death (Clinical Procedures and medical management) related deaths, Alcohol, drug and medication related deaths | 1 |
| 2021 | Kenneth Smith | Timothy Brennand | Care Home Health related deaths, Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2021 | Dyllon Milburn | Zak Golombeck | Community health care, Mental Health related deaths | 4 |
| 2021 | Wilfred Breakell | Brendan Allen | Community health care, Road (Highways Safety) related deaths | 1 |
| 2021 | Liam Kenyon | Joanne Kearsley | Community health care, Other related deaths | |
| 2021 | Bruce Houghton | Joanne Kearsley | Community health care, Alcohol, drug and medication related deaths | 3 |
| 2021 | Owen Hinds | Laurinder Bower | Community health care, Other related deaths | 1 |
| 2021 | Helen Spicer | Guy Davies | Alcohol, drug and medication related deaths, Community health care | 2 |
| 2021 | Macaulay Wilson | Mary Hassell | Community health care, Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2021 | Sarah Brady | Joanne Lees | Hospital Death (Clinical Procedures and medical management) related deaths, Alcohol, drug and medication related deaths | 1 |
| 2021 | Jade Rayner | Alison Mutch | Police related deaths, Alcohol, drug and medication related deaths | 2 |
| 2021 | Sean Kay | Sean Horstead | Mental Health related deaths, Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2021 | Alan Massam | Alison Mutch | Care Home Health related deaths, Hospital Death (Clinical Procedures and medical management) related deaths | 3 |
| 2021 | Mary Gwanyama | Caroline Topping | Hospital Death (Clinical Procedures and medical management) related deaths, Mental Health related deaths | 1 |
| 2021 | Ella Kissi-Debrah | Philip Barlow | Child Death (from 2015), Community health care | 12 |
| 2021 | Ailsa Stewart | Chris Morris | Community health care, Other related deaths | 1 |
| 2021 | Hannah Browning | John Gittins | Mental Health related deaths, Community health care | 1 |
| 2021 | Anthony Wilkinson | Abigail Combes | Community health care, Hospital Death (Clinical Procedures and medical management) related deaths | 3 |
| 2021 | Bathsheba Shepherd | Dr Sean Cummings | Community health care, Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2021 | Sean Fegan | Gordon Clow | Mental Health related deaths, Alcohol, drug and medication related deaths | 1 |
| 2021 | Andrew Biddlecombe | Jason Pegg | Community health care, Road (Highways Safety) related deaths | 1 |
| 2021 | Michael Dent-Jones | Anna Crawford | Alcohol, drug and medication related deaths, State Custody related deaths | 1 |
| 2021 | Lily-Mai George | Mary Hassell | Child Death (from 2015), Community health care | |
| 2021 | Jerome Peat | Dr Simon Fox Qc | Community health care, Alcohol, drug and medication related deaths | |
| 2021 | Cyril Cheetham | Andrew Bridgman | Community health care, Other related deaths | 2 |
| 2021 | Norma Bradbury | Andrew Bridgman | Community health care, Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2021 | Philip Sheridan | Kevin Mcloughlin | Community health care, Other related deaths | 1 |
| 2021 | Natalie Edgington | Catherine Mckenna | Community health care, Other related deaths | 1 |
| 2021 | Pardeep Plahe | Emma Brown | Community health care | 4 |
| 2020 | Steven Cooke | Emma Serrano | Community health care, Mental Health related deaths | |
| 2020 | Kalila Griffiths | Nadia Persaud | Hospital Death (Clinical Procedures and medical management) related deaths, Community health care | 1 |
| 2020 | Rory Attwood | Caroline Saunders | Mental Health related deaths, Alcohol, drug and medication related deaths | 1 |
| 2020 | Thomas Rawnsley | Abigail Combes | Emergency Services related deaths, Community health care | 2 |
| 2020 | Roy Curtis | Tom Osborne | Community health care, Suicide (from 2015) | 1 |
| 2020 | Violet Jackman | Alison Mutch | Child Death (from 2015), Community health care | 1 |
| 2020 | Geoffrey Banks | Margaret Jones | Alcohol, drug and medication related deaths, Community health care | 2 |
| 2020 | Eleanor Sherman | Sean Mcgovern | Community health care, Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2020 | Trinder Birdi | Nadia Persaud | Mental Health related deaths, Community health care | 1 |
| 2020 | David Ball | Emma Serrano | Suicide (from 2015), Mental Health related deaths | 2 |
| 2020 | Ann Schuetz | Hassan Shah | Hospital Death (Clinical Procedures and medical management) related deaths, Community health care | |
| 2020 | Alfie Gildea | Alison Mutch | Police related deaths, Child Death (from 2015) | 6 |
| 2020 | Ewan Brown | Carly Elizabeth Henley | Police related deaths, Mental Health related deaths | |
| 2020 | Linda Doherty | Anna Crawford | Hospital Death (Clinical Procedures and medical management) related deaths, Community health care | 1 |
| 2020 | Reggie-Jay Payne | Tom Osborne | Child Death (from 2015), Community health care | |
| 2020 | Karen Jane Winn | Nigel Parsley | Community health care, Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2020 | Roger Wood | Graeme Irvine | Community health care | |
| 2020 | Siân Hewitt | Tom Osborne | Community health care, Mental Health related deaths | |
| 2020 | Thomas King | Lincoln Brookes | Suicide (from 2015), Mental Health related deaths | 1 |
| 2020 | Brian Murphy | Alison Mutch | Hospital Death (Clinical Procedures and medical management) related deaths, Community health care | 1 |
| 2020 | Mavis Lawrence | Margaret Jones | Care Home Health related deaths, Community health care | 1 |
| 2020 | Joseph Cheetham | Alison Mutch | Community health care, Hospital Death (Clinical Procedures and medical management) related deaths | 3 |
| 2020 | Zak Farmer | Caroline Beasley Murray | Mental Health related deaths, Community health care | 2 |
| 2020 | June Winterbottom | Kevin Mcloughlin | Community health care | 1 |
| 2020 | Eileen Brindley | Joanne Lees | Community health care, Other related deaths | 1 |
| 2020 | Christine Forbes | Emma Serrano | Community health care | 1 |
| 2020 | Pauline Oakley | Jonathan Stevens | Other related deaths, Hospital Death (Clinical Procedures and medical management) related deaths | 3 |
| 2020 | Toby Nieland | Timothy Brennand | Alcohol, drug and medication related deaths, Community health care | 3 |
| 2020 | Viktor Scott-Brown | Oliver Longstaff | Suicide (from 2015), Community health care | 4 |
| 2020 | Francis Cooney | Emma Brown | Suicide (from 2015), Community health care | 1 |
| 2020 | Theresa Robertson | Graeme Irvine | Alcohol, drug and medication related deaths, Community health care | |
| 2020 | Amy Hogan | Christopher Morris | Alcohol, drug and medication related deaths, Community health care | 1 |
| 2020 | Gary Etherington | Andrew Harris | Mental Health related deaths, Community health care | 1 |
| 2020 | Omarian Brooks | Andrew Harris | Community health care | 3 |
| 2020 | Harrison Hassall | Professor Catherine Mason | Community health care, Child Death (from 2015) | 1 |
| 2020 | Patricia Ferguson | Gordon Clow | Mental Health related deaths, Suicide (from 2015) | 2 |
| 2020 | Sam Pringle | Jason Wells | Mental Health related deaths, Suicide (from 2015) | 1 |
| 2020 | Wendy Wilkes | Alison Mutch | Alcohol, drug and medication related deaths, Community health care | 2 |
| 2020 | Patricia McAdam | S Ormond Walshe | Community health care | |
| 2020 | Darren King | Nigel Parsley | Community health care | |
| 2020 | Danny Holt-Scapens | Rachel Syed | Mental Health related deaths, Community health care | |
| 2020 | John Ashley | Penelope Schofield | Mental Health related deaths, Suicide (from 2015) | |
| 2020 | Lee Carpenter | Nadia Persaud | Community health care, Mental Health related deaths | |
| 2020 | Thomas Reilly | Veronica Hamilton Deeley | Community health care, Mental Health related deaths | |
| 2020 | Anita Loi | Jacqueline Devonish | Community health care | 1 |
| 2020 | Billy Jenkins | Jacqueline Devonish | Alcohol, drug and medication related deaths, Mental Health related deaths | 1 |
| 2020 | Gemma Azhar | Bridget Dolan Qc | Suicide (from 2015), Mental Health related deaths | 1 |
| 2020 | David Clark | Neil Cronin | Mental Health related deaths, Community health care | 1 |
| 2020 | Julie O’Connor | Maria Voisin | Community health care | 1 |
| 2020 | Shanté Turay-Thomas | Mary Hassell | Emergency Services related deaths, Community health care | 9 |
| 2020 | Samantha Savage-Greene | Andrew Bridgman | Community health care, Mental Health related deaths | |
| 2020 | Madhavbhai Patel | Joanne Lees | Community health care | 1 |
| 2020 | James Wheeler | Chris Morris | Care Home Health related deaths, Community health care | 3 |
| 2019 | Jacob Bates | Peter Nieto | Community health care, Mental Health related deaths | 1 |
| 2019 | David Fowler | Rachel Galloway | Alcohol, drug and medication related deaths, Community health care | 1 |
| 2019 | Lewis Mendelson | Alison Mutch | Community health care | 2 |
| 2019 | Heather Planner | Crispin Butler | Community health care | |
| 2019 | John Wells | Robert Simpson | Community health care, Emergency services related deaths (2019 onwards) | |
| 2019 | Safoora Alam | Zafar Siddique | Community health care, Suicide (from 2015) | 2 |
| 2019 | Alex Grady | Catherine Mckenna | Community health care, Alcohol, drug and medication related deaths | |
| 2019 | Joanna Flynn | Caroline Beasley Murray | Community health care, Alcohol, drug and medication related deaths | 3 |
| 2019 | Dorothy Macey | Sonia Hayes | Community health care | |
| 2019 | Sandra Scott | David Urpeth | Community health care, Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2019 | Annie Lloyd | Zafar Siddique | Community health care | 1 |
| 2019 | Iain Macinnes | Tom Osborne | Mental Health related deaths, Community health care | |
| 2019 | Kathryn Barrow | Chris Morris | Community health care | |
| 2019 | Graham Saffery | Emma Whitting | Community health care, Alcohol, drug and medication related deaths | 1 |
| 2019 | Shannon Quinn | Zafar Siddique | Mental Health related deaths, Community health care | 2 |
| 2019 | Evelyn Swift | Elizabeth Didcock | Community health care | |
| 2019 | Deborah Chapman | Adrian Farrow | Community health care, Alcohol, drug and medication related deaths | 1 |
| 2019 | Nigel Abbott | James Bennett | Community health care, Emergency services related deaths (2019 onwards) | 1 |
| 2019 | Miriam Tighe | Rachel Galloway | Care Home Health related deaths, Community health care | |
| 2019 | Feni Lee | Philip Barlow | Community health care | 1 |
| 2019 | Frank Stockton | Tim Holloway | Community health care, Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2019 | Charles Knapp | Anna Crawford | Community health care | |
| 2019 | Shahida Begum | Nadia Persaud | Community health care, Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2019 | Beverley Shaw | Joanne Kearsley | Community health care | 3 |
| 2019 | Geoffrey Duke | Margaret Jones | Hospital Death (Clinical Procedures and medical management) related deaths, Community health care | 3 |
| 2019 | Peter Moran | Margaret Jones | Community health care, Emergency services related deaths (2019 onwards) | 1 |
| 2019 | Anthony Walker | David Clark | Suicide (from 2015), Community health care | 3 |
| 2019 | Brian Goodman | Sarah Bourke | Community health care | 1 |
| 2019 | Yong Hong | Sonia Hayes | Care Home Health related deaths, Community health care | |
| 2019 | Jack May | Rachel Knight | Community health care, Wales prevention of future deaths reports (2019 onwards) | 1 |
| 2019 | Theresa Feehan | Fiona Wilcox | Community health care | 1 |
| 2019 | Simon Barber | Tanyka Rawden | Community health care | 1 |
| 2019 | George Thompson | Christopher Morris | Community health care | 1 |
| 2019 | Jacqueline Elliott | Alison Mutch | Alcohol, drug and medication related deaths, Community health care | 1 |
| 2019 | Christopher Seal | Maria Voisin | Community health care, Mental Health related deaths | 1 |
| 2018 | REDACTED | Henrietta Hill Qc | Community health care, Suicide (from 2015) | 1 |
| 2015 | Ronald Bonfield | Community health care, Emergency Services related deaths | ||
| 2015 | Miriam Smith-Cox | Elizabeth Emma Carlyon | Community health care, Other related deaths | 2 |
| 2013 | Jacqueline Allwood | Andrew Harris | Community health care, Emergency Services related deaths | 1 |
| 2013 | James Edward Mansfield | Mrs Cheney | Community health care | |
| 0000-00-00 | Alphonso Shearer | Alison Mutch | Hospital Death (Clinical Procedures and medical management) related deaths, Community health care | 3 |
| 0000-00-00 | Lauren Murdock | Mary Hassell | Community health care, Alcohol, drug and medication related deaths | 3 |
| 0000-00-00 | James Taylor | Nadia Persaud | Community health care, Mental Health related deaths | 2 |
| 0000-00-00 | Coral O’Donnell | Alan Wilson | Hospital Death (Clinical Procedures and medical management) related deaths, Community health care | 2 |
| 0000-00-00 | 2021-0184 | Nicholas Moss Qc | Community health care, Mental Health related deaths | 3 |
| 0000-00-00 | James Herbertson | Penelope Schofield | Hospital Death (Clinical Procedures and medical management) related deaths, Community health care | 1 |
| 0000-00-00 | Irene Esaw | Anna Morris | Hospital Death (Clinical Procedures and medical management) related deaths, Community health care | 1 |
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