18 Prevention of Future Deaths reports written by Crispin Butler, 2015–2026. 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.
11 of 18 (61%) 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 | Category | Responses |
|---|---|---|---|
| 2026 | Barry Harmer | Mental Health related deaths | |
| 2025 | George Emmett | State Custody related deaths, Alcohol, drug and medication related deaths | 1 |
| 2024 | Fern Foster | Suicide (from 2015) | 3 |
| 2023 | Haik Nikolyan | State Custody related deaths, Suicide (from 2015) | 1 |
| 2023 | Anthony Rockall | Other related deaths | |
| 2021 | Mollie Dimmock | Child Death (from 2015), Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2021 | Roy Morris | Hospital Death (Clinical Procedures and medical management) related deaths, Suicide (from 2015) | 1 |
| 2019 | Heather Planner | Community health care | |
| 2019 | Alf Rewin | Alcohol, drug and medication related deaths | 1 |
| 2019 | Jaspal Singh Bahra | Other related deaths | 1 |
| 2019 | Emma Butler | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2018 | Joyce Long | Community health care and emergency services related deaths, Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2018 | Lewis Colgan | Hospital Death (Clinical Procedures and medical management) related deaths, Mental Health related deaths | |
| 2017 | Helen Bannister | Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2017 | Arthur Morley | State Custody related deaths | |
| 2017 | Jack Portland | Hospital Death (Clinical Procedures and medical management) related deaths, State Custody related deaths | 2 |
| 2016 | Stephen Bird | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2015 | Robert Hogg | Child Death (from 2015), Hospital Death (Clinical Procedures and medical management) related deaths | 2 |
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