Wales prevention of future deaths reports (2019 onwards)

180 Prevention of Future Deaths reports categorised Wales prevention of future deaths reports (2019 onwards), 2019–2026. 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.

Reports per year

201929
202012
202118
202224
202318
202436
202537
20266

Responses published

156 of 180 (87%) 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.

Coroners

Caroline Saunders 27John Gittins 27Rachel Knight 17Kate Robertson 13Graeme Hughes 12David Regan 11Aled Gruffydd 8Kate Sutherland 7Kirsten Heaven 5Patricia Morgan 4Kerrie Burge 4Colin Phillips 4Sarah Jane Richards 4Gavin Knox 4

Reports

DateReportCoronerCategoryResponses
2026Summer MantRachel KnightChild Death (from 2015), Wales prevention of future deaths reports (2019 onwards)
2026Helen Patching, Rachael Patching and Corey LongdonRachel KnightOther related deaths, Wales prevention of future deaths reports (2019 onwards)
2026Della CalveyCaroline SaundersHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)2
2026Joan Read Prevention of future deaths reportRachel KnightHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2026Ryan Harding Prevention of future deaths reportDavid ReganAlcohol, drug and medication related deaths, Wales prevention of future deaths reports (2019 onwards)1
2026Lyn MaherRachel KnightAlcohol, drug and medication related deaths, Wales prevention of future deaths reports (2019 onwards)1
2025Matthew Singh Prevention of future deaths reportKate RobertsonState Custody related deaths, Wales prevention of future deaths reports (2019 onwards)1
2025Oliver GormanAndrew BridgmanChild Death (from 2015), Wales prevention of future deaths reports (2019 onwards)4
2025Alexander LewisAled GruffyddRoad (Highways Safety) related deaths, Wales prevention of future deaths reports (2019 onwards)3
2025Caitlin ImberJohn GittinsMental Health related deaths, Wales prevention of future deaths reports (2019 onwards)1
2025Theo Treharne-JonesGavin KnoxChild Death (from 2015), Other related deaths2
2025Milos JankovicRachel KnightHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)2
2025Pamela SinghGavin KnoxOther related deaths, Wales prevention of future deaths reports (2019 onwards)1
2025Brian DaviesAled GruffyddOther related deaths, Wales prevention of future deaths reports (2019 onwards)2
2025Gareth JohnsonKerrie BurgeHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)2
2025Peter ThomasRachel KnightHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2025Edward FunnellAndrew MorseHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2025Lewis PetryszynPatricia MorganState Custody related deaths, Wales prevention of future deaths reports (2019 onwards)1
2025Robyn ChambersCaroline SaundersChild Death (from 2015), Emergency services related deaths (2019 onwards)1
2025Liliwen ThomasRachel KnightChild Death (from 2015), Hospital Death (Clinical Procedures and medical management) related deaths1
2025Valerie HillGraeme HughesCare Home Health related deaths, Hospital Death (Clinical Procedures and medical management) related deaths1
2025Valerie HillGraeme HughesEmergency services related deaths (2019 onwards), Wales prevention of future deaths reports (2019 onwards)1
2025David EjimoforEdward RamsayChild Death (from 2015), Wales prevention of future deaths reports (2019 onwards)3
2025Jeanette Sidlow BeechKate RobertsonAlcohol, drug and medication related deaths, Emergency services related deaths (2019 onwards)1
2025Marina WaldronCaroline SaundersHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2025Etta-Lili Stockwell-ParryKate RobertsonChild Death (from 2015), Hospital Death (Clinical Procedures and medical management) related deaths1
2025Robert SmithAndrew MorseSuicide (from 2015), Wales prevention of future deaths reports (2019 onwards)1
2025Christopher BrazilLouisa CorcoranAlcohol, drug and medication related deaths, Wales prevention of future deaths reports (2019 onwards)2
2025Martin SaundersKerrie BurgeRoad (Highways Safety) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2025Patricia CatterallJohn GittinsCare Home Health related deaths, Wales prevention of future deaths reports (2019 onwards)2
2025Emma HillJohn GittinsWales prevention of future deaths reports (2019 onwards), Road (Highways Safety) related deaths1
2025Leanne CarrollKate RobertsonMental Health related deaths, Wales prevention of future deaths reports (2019 onwards)1
2025Colin ColleyRachel KnightHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2025Rhiannon WilliamsKirsten HeavenSuicide (from 2015), Wales prevention of future deaths reports (2019 onwards)2
2025Jean PikeKirsten HeavenSuicide (from 2015), Mental Health related deaths1
2025Annette LewisKerrie BurgeHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2025Amy PadleyKirsten HeavenHospital Death (Clinical Procedures and medical management) related deaths, Mental Health related deaths1
2025Ann CotgroveJohn GittinsHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2025Jeffrey TylerCaroline SaundersEmergency services related deaths (2019 onwards), Wales prevention of future deaths reports (2019 onwards)1
2025Ian JonesGavin KnoxRoad (Highways Safety) related deaths, Product related deaths1
2025Carl Butler and Sean BrettJohn GittinsRoad (Highways Safety) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2025Donald MitchellPatricia MorganRoad (Highways Safety) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2025Jackson YeowDavid ReganChild Death (from 2015), Emergency services related deaths (2019 onwards)1
2024Huw ErasmusCaroline SaundersWales prevention of future deaths reports (2019 onwards), Hospital Death (Clinical Procedures and medical management) related deaths1
2024Muhammad & Naemat EsmaelKirsten HeavenWales prevention of future deaths reports (2019 onwards), Product related deaths2
2024Andrew HowatJohn GittinsRoad (Highways Safety) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2024Margaret DalyJohn GittinsWales prevention of future deaths reports (2019 onwards), Hospital Death (Clinical Procedures and medical management) related deaths1
2024Shirley HughesJohn GittinsWales prevention of future deaths reports (2019 onwards), Emergency services related deaths (2019 onwards)1
2024Jean ThomasCaroline SaundersWales prevention of future deaths reports (2019 onwards), Hospital Death (Clinical Procedures and medical management) related deaths1
2024Peter ParkerAled GruffyddEmergency services related deaths (2019 onwards), Wales prevention of future deaths reports (2019 onwards)3
2024Wilfred Fitchett, Jevon Hirst, Hugo Morris and Harvey OwenKate RobertsonRoad (Highways Safety) related deaths, Wales prevention of future deaths reports (2019 onwards)3
2024John FollonGaynor KynastonHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2024Sara GrinnellPatricia MorganHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2024Kay SimmondsCaroline SaundersAlcohol, drug and medication related deaths, Wales prevention of future deaths reports (2019 onwards)1
2024Marjorie MichaelCaroline SaundersEmergency services related deaths (2019 onwards), Wales prevention of future deaths reports (2019 onwards)1
2024Philips EvansKate RoberstonHospital Death (Clinical Procedures and medical management) related deaths, Alcohol, drug and medication related deaths1
2024Paul RobertsJohn GittinsMental Health related deaths, Hospital Death (Clinical Procedures and medical management) related deaths1
2024Isobel StapletonDavid ReganSuicide (from 2015), Wales prevention of future deaths reports (2019 onwards)2
2024Susan WilliamsPaul BennettHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)2
2024Stefan WalkerEdward RamsayAlcohol, drug and medication related deaths, Wales prevention of future deaths reports (2019 onwards)1
2024Eric ThompsonKate RobertsonHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2024Clara WinterKerrie BurgeHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2024Sylvia EvansCaroline SaundersEmergency services related deaths (2019 onwards), Wales prevention of future deaths reports (2019 onwards)1
2024Ben HarrisonKate RobertsonHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2024Nicholas HarrisonKirsten HeavenOther related deaths, Mental Health related deaths4
2024Maureen OwensJohn GittinsHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2024Alan DaviesDavid ReganState Custody related deaths, Wales prevention of future deaths reports (2019 onwards)3
2024Neil EdwardsCaroline SaundersHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2024Jane WalkerKate RobertsonOther related deaths, Alcohol, drug and medication related deaths1
2024Jean ThomasAled GruffyddEmergency services related deaths (2019 onwards), Wales prevention of future deaths reports (2019 onwards)2
2024Jennifer TriggerJohn GittinsHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2024Nesta JonesKate RobertsonHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2024Benjamin LeonardDavid PojurChild Death (from 2015), Other related deaths8
2024Joseph CattleGavin KnoxAlcohol, drug and medication related deaths, Wales prevention of future deaths reports (2019 onwards)1
2024Teresa BennettSarah RileyAlcohol, drug and medication related deaths, Wales prevention of future deaths reports (2019 onwards)1
2024Mouayed BashirCaroline SaundersAlcohol, drug and medication related deaths, Wales prevention of future deaths reports (2019 onwards)1
2024Brian JamesPatricia MorganEmergency services related deaths (2019 onwards), Wales prevention of future deaths reports (2019 onwards)1
2024Philip TaylorKate RobertsonSuicide (from 2015), Wales prevention of future deaths reports (2019 onwards)2
2024Christopher KapessaDavid ReganChild Death (from 2015), Other related deaths1
2023Lynda BlackmoreGraeme HughesEmergency services related deaths (2019 onwards), Wales prevention of future deaths reports (2019 onwards)3
2023Bronwen MorganGraeme HughesSuicide (from 2015), Wales prevention of future deaths reports (2019 onwards)
2023Jennifer CampbellKate RobertsonHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2023Richard GriffithsKate RobertsonSuicide (from 2015), Wales prevention of future deaths reports (2019 onwards)1
2023Rashdah BhattiJohn GittinsWales prevention of future deaths reports (2019 onwards), Emergency services related deaths (2019 onwards)1
2023Mary JonesKate RobertsonWales prevention of future deaths reports (2019 onwards), Emergency services related deaths (2019 onwards)1
2023Emlyn RobertsJohn GittinsWales prevention of future deaths reports (2019 onwards), Emergency services related deaths (2019 onwards)
2023Jean FrickelKate SutherlandWales prevention of future deaths reports (2019 onwards), Emergency services related deaths (2019 onwards)
2023Leonard HarmsworthKate SutherlandWales prevention of future deaths reports (2019 onwards), Emergency services related deaths (2019 onwards)
2023Andrew ShambrookJohn GittinsSuicide (from 2015), Wales prevention of future deaths reports (2019 onwards)1
2023Nancy PriceKate SutherlandHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2023Ben HarrisonKate SutherlandSuicide (from 2015), Wales prevention of future deaths reports (2019 onwards)
2023David StrachanKate SutherlandWales prevention of future deaths reports (2019 onwards), Emergency services related deaths (2019 onwards)2
2023Twm BrynSarah RileyWales prevention of future deaths reports (2019 onwards), Suicide (from 2015)1
2023Hannah WarrenEdward RamsayOther related deaths, Wales prevention of future deaths reports (2019 onwards)3
2023Mary WhiteNaomi ReesWales prevention of future deaths reports (2019 onwards), Hospital Death (Clinical Procedures and medical management) related deaths1
2023Dorothy JonesCaroline SaundersEmergency services related deaths (2019 onwards), Wales prevention of future deaths reports (2019 onwards)2
2023Lucy JonesCaroline SaundersSuicide (from 2015), Wales prevention of future deaths reports (2019 onwards)1
2022Emma PowellJohn GittinsOther related deaths, Wales prevention of future deaths reports (2019 onwards)2
2022Glenys PhippsCaroline SaundersHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2022Yvonne RankinRachel KnightHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)2
2022Akeem RhodenRachel KnightOther related deaths, Wales prevention of future deaths reports (2019 onwards)2
2022Susan PerryGraeme HughesAlcohol, drug and medication related deaths, Wales prevention of future deaths reports (2019 onwards)1
2022Maria WhaleSarah Jane RichardsWales prevention of future deaths reports (2019 onwards), Emergency services related deaths (2019 onwards)2
2022John WhiteGraeme HughesSuicide (from 2015), Wales prevention of future deaths reports (2019 onwards)
2022Glendys RobertsKate SutherlandEmergency services related deaths (2019 onwards), Wales prevention of future deaths reports (2019 onwards)2
2022Matthew RouchRachel KnightWales prevention of future deaths reports (2019 onwards), Road (Highways Safety) related deaths1
2022Aaron EdwardsRachael KnightRoad (Highways Safety) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2022Gareth WilliamsCaroline SaundersSuicide (from 2015), Wales prevention of future deaths reports (2019 onwards)1
2022Hemanta RaiRachel KnightOther related deaths, Wales prevention of future deaths reports (2019 onwards)2
2022Kieran CrimminsPaul BennettSuicide (from 2015), Mental Health related deaths
2022Gwynne SamuelCaroline SaundersEmergency services related deaths (2019 onwards), Wales prevention of future deaths reports (2019 onwards)1
2022Raymond GillespieKate SutherlandEmergency services related deaths (2019 onwards), Wales prevention of future deaths reports (2019 onwards)
2022Michael WilliamsJohn GittinsRoad (Highways Safety) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2022Donald ComptonDr Sarah Jane RichardsWales prevention of future deaths reports (2019 onwards), Hospital Death (Clinical Procedures and medical management) related deaths
2022Margaret LewisDr Sarah Jane RichardsWales prevention of future deaths reports (2019 onwards), Road (Highways Safety) related deaths1
2022Marvin RueCaroline SaundersHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)
2022Sarah Gilbert-JonesGraeme HughesEmergency services related deaths (2019 onwards), Mental Health related deaths1
2022Eirlys RobertsKatie SutherlandCare Home Health related deaths, Wales prevention of future deaths reports (2019 onwards)2
2022Barbara YoungCaroline SaundersEmergency services related deaths (2019 onwards), Wales prevention of future deaths reports (2019 onwards)1
2022Brian WarehamCaroline SaundersWales prevention of future deaths reports (2019 onwards), Community health care2
2022Ian MillerCaroline SaundersState Custody related deaths, Suicide (from 2015)1
2021Eva WheelerRachel KnightHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2021Jonathan BaylissKatie SutherlandAccident at Work and Health and Safety related deaths, Service Personnel related deaths1
2021Robert ElleryDavid ReganState Custody related deaths, Wales prevention of future deaths reports (2019 onwards)1
2021Mustafa AbdelkarimCaroline SaundersWales prevention of future deaths reports (2019 onwards), Other related deaths1
2021Daniel HallDr Sarah Jane RichardsMental Health related deaths, Suicide (from 2015)1
2021Mared FoulkesKatie SutherlandSuicide (from 2015), Other related deaths1
2021Susan MertonJohn GittinsHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2021Robert WrightDavid ReganHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2021Steven EvansCaroline SaundersOther related deaths, Wales prevention of future deaths reports (2019 onwards)2
2021Kyle HurstJohn GittinsHospital Death (Clinical Procedures and medical management) related deaths, Suicide (from 2015)1
2021Siwan SmithCaroline SaundersCommunity health care, Mental Health related deaths1
2021Suzanne ReganColin PhillipsRoad (Highways Safety) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2021Catherine BestAled GruffyddHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2021Rhian RobertsJohn GittinsHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)
2021Valmai WestCaroline SaundersHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2021Lynne LawrenceCaroline SaundersRoad (Highways Safety) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2021Roy EvansPeter BruntonAccident at Work and Health and Safety related deaths, Road (Highways Safety) related deaths2
2021Hannah BrowningJohn GittinsMental Health related deaths, Community health care1
2020Rory AttwoodCaroline SaundersMental Health related deaths, Alcohol, drug and medication related deaths1
2020Brian GriffithsColin PhillipsRoad (Highways Safety) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2020Andres RobertsColin PhillipsEmergency Services related deaths, Wales prevention of future deaths reports (2019 onwards)2
2020Alyn ReesCaroline SaundersEmergency Services related deaths, Wales prevention of future deaths reports (2019 onwards)
2020Dean GeorgeColin PhillipsAlcohol, drug and medication related deaths, State Custody related deaths1
2020Ian WeeksGeraint WilliamsState Custody related deaths, Suicide (from 2015)1
2020Arthur HughesJohn GittinsHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2020Darren GoddardSarah Jane RichardsHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2020Lewys CrawfordGraeme HughesHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)
2020Jon JamesRachel KnightAlcohol, drug and medication related deaths, Police related deaths1
2020Benjamin LeonardDavid PojurChild Death (from 2015), Other related deaths1
2020Deborah LamontGraeme HughesSuicide (from 2015), Wales prevention of future deaths reports (2019 onwards)2
2019Samantha BrousasJoanna LeesEmergency services related deaths (2019 onwards), Wales prevention of future deaths reports (2019 onwards)1
2019Mark AndersonSarah Jane RichardsRoad (Highways Safety) related deaths, Wales prevention of future deaths reports (2019 onwards)
2019Luke JonesJohn GittinsAlcohol, drug and medication related deaths, State Custody related deaths1
2019Connor DaviesGeraint WilliamsHospital Death (Clinical Procedures and medical management) related deaths, Suicide (from 2015)1
2019Thomas BrowneDavid ReganHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)
2019Pamela MoranAled GruffyddHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)
2019Peter ConnellyJohn GittinsHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)
2019Paul McleanGraeme HughesEmergency services related deaths (2019 onwards), Wales prevention of future deaths reports (2019 onwards)1
2019Jane LivingtonAled GruffyddMental Health related deaths, Suicide (from 2015)1
2019Edna EvansJohn GittinsCare Home Health related deaths, Wales prevention of future deaths reports (2019 onwards)
2019Annette HewinsGraeme HughesHospital Death (Clinical Procedures and medical management) related deaths, Mental Health related deaths1
2019Ffion JonesDavid ReganEmergency services related deaths (2019 onwards), Wales prevention of future deaths reports (2019 onwards)
2019Christopher SummerhayesSarah Jane RichardsHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2019Barbara HumphreysIan BoyesCare Home Health related deaths, Wales prevention of future deaths reports (2019 onwards)1
2019Carl SargeantJohn GittinsSuicide (from 2015), Wales prevention of future deaths reports (2019 onwards)1
2019Glenys ButtonRachel KnightHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2019Emily InglisMark LaytonHospital Death (Clinical Procedures and medical management) related deaths, Mental Health related deaths
2019Jenson FrancisDavid ReganChild Death (from 2015), Hospital Death (Clinical Procedures and medical management) related deaths1
2019Marion PranceRachel KnightEmergency services related deaths (2019 onwards), Wales prevention of future deaths reports (2019 onwards)1
2019Michael DaviesJonathan LaytonEmergency services related deaths (2019 onwards), Wales prevention of future deaths reports (2019 onwards)1
2019Jennifer HandyRachael KnightChild Death (from 2015), Hospital Death (Clinical Procedures and medical management) related deaths2
2019Kristopher McDowellJohn GittinsOther related deaths, Wales prevention of future deaths reports (2019 onwards)1
2019Meirion JamesPaul BennettMental Health related deaths, State Custody related deaths
2019Jack MayRachel KnightCommunity health care, Wales prevention of future deaths reports (2019 onwards)1
2019Keith HeatleyIan BoyesHospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2019Lyn MorganAled GruffyddRoad (Highways Safety) related deaths, Wales prevention of future deaths reports (2019 onwards)1
2019Matthew LewisGraeme HughesEmergency services related deaths (2019 onwards), Suicide (from 2015)2
2019Calary DavisDavid ReganChild Death (from 2015), Hospital Death (Clinical Procedures and medical management) related deaths1
2019Madeline StaplesJohn GittinsHospital Death (Clinical Procedures and medical management) related deaths, Emergency services related deaths (2019 onwards)

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