45 Prevention of Future Deaths reports name this organisation, 2013–2026. Every report below links to the original on judiciary.uk.
35 of 45 reports (78%) have at least one response published on judiciary.uk.
For reports written in the same years, 75% of all PFD reports in the corpus have a published response — so this page is in line with the corpus rate — the difference is within what chance alone would produce for this few reports.
This is not a reply rate. It counts responses published against the report by anyone — the organisation named here, a government department, a regulator or another body — because most response letters do not identify their author in a form that can be resolved reliably. A report with no response listed does not mean nobody replied: publication is at the discretion of the Chief Coroner's office, is often delayed, and was far less consistent in the corpus's early years. Treat a low figure as a prompt to read the reports, not as a finding about this organisation.
| Date | Report | Category | Coroner | Response | |
|---|---|---|---|---|---|
| 24 Mar 2026 | Ronald Meikle | State Custody related deaths | Sean Cummings | HM Prison Probation service, Central North West London NHS Foundation Trust | source |
| 24 Nov 2025 | Diana Grant | State Custody related deaths | Mental health related deaths | Richard Travers | Department of Health and Social Care, NHS England | source |
| 1 Aug 2025 | Brian Ringrose | Alcohol, drug and medication related deaths | Police related deaths | Sean Cummings | Milton Keynes University Hospitals, Central and North West London NHS Foundation Trust, Thames Valley Police | source |
| 18 Jun 2025 | Edward Cassin | Hospital Death (Clinical Procedures and medical management) related deaths | Sean Cummings | Central North West London NHS Foundation Trust, Milton Keynes University Hospita | source |
| 4 Apr 2025 | Alexi Susiluoto | Alcohol, drug and medication related deaths | R Brittain | MHCLG, DHSC | source |
| 15 Jan 2025 | Sheila Wexler | Product related deaths | Ian Potter | NRS Healthcare, NHS England | source |
| 10 Oct 2024 | Florence Stewart | Suicide (from 2015) | Mental Health related deaths | Hospital Death (Clinical Procedures and medical management) related deaths | Tom Osborne | Central and NW London NHS Trust | source |
| 7 Mar 2024 | Adrian James | Mental Health related deaths | Suicide (from 2015) | Fiona Wilcox | Central and North West London, NHS England | source |
| 7 Mar 2024 | David Siirak | Other related deaths | Richard Furniss | Central and North West London NHS Foundation Trust | source |
| 16 Feb 2024 | Roberto Bottello | Mental Health related deaths | Fiona Wilcox | Central and NW London NHS, Metropolitan Police Service, NHS England | source |
| 25 Oct 2023 | Federica Cavenati | Suicide (from 2015) | Priya Malhotra | none published | source |
| 2 Oct 2023 | Jack Zarrop | Suicide (from 2015) | Anton Van Dellen | the Home Office, NHSE, National Police Chiefs Council | source |
| 16 Aug 2023 | Odichukwumma Igweani | Mental Health related deaths | Sean Cummings | Central and North West London NHS Foundation Trust, Red House Surgery, Bedfordshire Luton and Milton Keynes Integrated Care Board | source |
| 15 Nov 2022 | Robert Kelly | Suicide (from 2015) | Tom Osborne | Milton Keynes University Hospital, Central and North West London NHS Foundation Trust | source |
| 21 Oct 2022 | Daniel O’Sullivan | Suicide (from 2015) | Alcohol, drug and medication related deaths | Christopher Williams | Central and North West London NHS Foundation Trust, Department of Health and Social Care | source |
| 20 Oct 2022 | Clifford Rose | Care Home Health related deaths | Tom Osborne | Milton Keynes City Council, Central and North West London NHS Foundation Trust | source |
| 24 Jun 2022 | Zsolt Kirjak | Suicide (from 2015) | Mental Health related deaths | Russell Caller | none published | source |
| 22 Oct 2021 | Anthony Clacher | State Custody related deaths | Mental Health related deaths | Alcohol, drug and medication related deaths | Other related deaths | Rachael Griffin | NHS Digital, HMPPS, Department of Health Social Care, NHS England and NHS Improvement | source |
| 22 Jun 2021 | Serena Nicolle | State Custody related deaths | Anna Crawford | none published | source |
| 28 Mar 2021 | Bathsheba Shepherd | Community health care | Hospital Death (Clinical Procedures and medical management) related deaths | Mental Health related deaths | Other related deaths | Dr Sean Cummings | none published | source |
| 6 Jul 2020 | Prince Fosu | State Custody related deaths | Chinyere Inyama | Indepedent Monitoring Board, Central and North West London NHS Foundation Trust | source |
| 21 Feb 2020 | Andrew Goldstraw | Alcohol, drug and medication related deaths; State custody related deaths; Suicide (from 2015) | Simon Burge | Central and North West London Foundation Trust | source |
| 26 Jul 2019 | William Vickers | Emergency services related deaths (2019 onwards); State Custody related deaths | Tom Osborne | CNWL NHS Trust, HM Prison and Probation Service | source |
| 29 Apr 2019 | Georgia Nelson | Railway related deaths; Mental Health related deaths | Fiona Wilcox | RBKC, CNWL NHS Trust | source |
| 2 Apr 2019 | Tarek Chowdhury | Hospital Death (Clinical Procedures and medical management) related deaths; State Custody related deaths | Richard Furniss | none published | source |
| 27 Feb 2019 | Peter Garvin | Mental Health related deaths; Suicide (from 2015) | Fiona Wilcox | CNWL NHS Trust | source |
| 25 Feb 2019 | John Pearce | Hospital Death (Clinical Procedures and medical management) related deaths | Edwin Buckett | CNWL NHS Trust | source |
| 19 Dec 2018 | Kirsty Walker | Hospital Death (Clinical Procedures and medical management) related deaths | Anna Crawford | Department of Health and Social Care, NHS England | source |
| 24 Oct 2018 | Maximilien Kohler | Mental Health related deaths; Child Death (from 2015) | Fiona Wilcox | Department of Health Social Care, Central and North West London NHS Trust | source |
| 19 Sep 2018 | Grenfell Tower | Other related deaths | Fiona Wilcox | none published | source |
| 9 Aug 2017 | Sean Plumstead | State Custody related deaths | Grahame Short | HM Prison Probation Services, HM Prison Probation Services.2 1, Carillion | source |
| 28 Jul 2017 | Sarah Reed | Suicide (from 2015); State Custody related deaths | Mental Health related deaths | Hospital Death (Clinical Procedures and medical management) related deaths | Sir Peter Thornton QC | CNWL NHS Trust, NOMS | source |
| 21 Feb 2017 | Jack Portland | Hospital Death (Clinical Procedures and medical management) related deaths; State Custody related deaths | Crispin Butler | Oxford Health NHS Trust, NOMS | source |
| 27 Nov 2016 | Matthew Russell | State Custody related deaths; Suicide (from 2015) | Richard Travers | Central and North West London NHS Trust | source |
| 4 Oct 2016 | Haydn Burton | State Custody related deaths; Suicide (from 2015) | Grahame Short | NOMS | source |
| 26 May 2016 | Ian Brown | State Custody related deaths; Suicide (from 2015) | Thomas Osborne | NOMS | source |
| 16 May 2016 | Sheldon Woodford | State Custody related | Sarah Whitby | none published | source |
| 6 Jul 2015 | Tommy Faisali | Hospital Death (Clinical Procedures and medical management) related deaths | Fiona Wilcox | none published | source |
| 28 Dec 2014 | Alex Kelly | State Custody related deaths | Patricia Harding | Medway Youth Offending Service, Oxleas NHS Trust, Tower Hamlets, Ministry of Justice, Central North West London NHS Trust | source |
| 8 Aug 2014 | Sean Brock | State Custody related deaths | Tom Osborne | NOMS | source |
| 2 Jul 2014 | Farres Ikken | Other related deaths | Andrew Walker | none published | source |
| 22 Apr 2014 | Rosemary Oladejo | Hospital Death (Clinical Procedures and medical management) related deaths | Chinyere Inyama | Hillingdon Commissioning Group, Central North West London NHS Trust | source |
| 15 Apr 2014 | Kevin Scarlett | State Custody related deaths | Tom Osborne | NOMS | source |
| 19 Feb 2014 | Simon McAndrew | Hospital Death (Clinical Procedures and medical management) related deaths | Dr R N Palmer | none published | source |
| 13 Dec 2013 | Stephanie Daniels | Hospital Death (Clinical Procedures and medical management) related deaths | Nigel Meadows | Manchester Mental Health NHS, Manchester Clinical Commissioning Groups, Department of Health | source |
These counts are a floor, not a total. A report is listed here only when it names the organisation in text our pipeline could read; scanned reports with poor OCR, and reports that name only a hospital site or an individual, are missed. Always check the source report.
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