Inquests - Prevention of Future Deaths reports
When Dave Sheppard retired in 2020 he kindly gave me permission to publish the contents of his website (originally named after his firm, "Dave Sheppard Associates", then called "MHAandMCA"). It is a treasure trove. I've not had time to prepare everything for publication but have put the main headings online: let me know if you would like a copy of anything listed.
Rule 43 reports were replaced on implementation of the Coroners and Justice Act 2009 with Reports on Action to Prevent Future Deaths ('reports') under paragraph 7, Schedule 5, of the 2009 Act and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. For short they can be referred to as PFDs or PFD reports or Regulation 28 reports. These reports are important. Coroners have a duty not just to decide how somebody came by their death but also, where appropriate, to report about that death with a view to preventing future deaths. A bereaved family wants to be able to say: 'His death was tragic and terrible, but at least it shouldn't happen to somebody else.' The importance of PFD reports is emphasised by their upgrading by Parliament from a rule (Rule 43 of the Coroners Rules 1984) to part of the 2009 Act (para.7, Schedule 5) and by changing the coroner's discretion to make a report to a duty to make a report where a concern is identified. Responsibility for reports was transferred from the Ministry of Justice to the Chief Coroner's office on 1 April 2013. The Chief Coroner has expressed his commitment to taking value from reports with a view to encouraging persons and organisations to make changes which may prevent future deaths.
Chief Coroner guidance No.5, Reports to prevent future deaths, updated January 2016
Independent Advisory Panel (IAP) on Deaths in Custody (external link)
Reports to prevent future deaths (external link)
Reports to prevent future deaths
(Ordered by date inquest concluded)
Deborah Lamont, South Wales Central, 17th January 2020
David Richard Fowler, Greater Manchester West , 20th December 2019
Kieran Hubbard, Manchester City, 12th December 2019
Peter Bates, Derby & Derbyshire, 5th December 2019
Gemma Macdonald, Suffolk, 5th December 2019
Callie Lewis, Central and South East Kent, 29th November 2019
Thomas Wedrychowski, Wiltshire and Swindon, 28th November 2019
Bethany Tenquist, City of Brighton & Hove, 22nd November 2019
Nimo Younis, Inner North London, 18th November 2019
Katharine Stamp, West Sussex, 8th November 2019
Charlotte Grace, Cumbria, 29th October 2019
Douglas Oak, Dorset, 22nd October 2019
Matthew George Kaliniecki Williamson, West London, 11th October 2019
Abdelslam Benelghazi, Avon, 9th October 2019
Jane Livingston, Swansea Neath & Port Talbot, 30th September 2019
Nigel Abbott, Birmingham and Solihull, 30th September 2019
Emily Sims, Cornwall and the Isles of Scilly, 27th September 2019
Oliver Sharp, Greater Manchester South, 20th September 2019
Annette Hewins, South Wales Central, 19th September 2019
Karis Braithwaite, East London, 17th September 2019
William Moody, Hampshire, 16th September 2019
Tyla Cook, Norfolk, 16th September 2019
Blaithin Grianne Buckley, Northamptonshire, 13th September 2019
Maureen Margaret Jarvis, Staffordshire South, 10th September 2019
Gurdeep Singh Dundhal, Birmingham and Solihull, 9th September 2019
Anthony McCormack, Birmingham and Solihull, 27th August 2019
Philip Owen, Greater Manchester South, 22nd August 2019
Tony Dunne, Inner North London, 19th August 2019
Daniel Shorrocks, Plymouth, Torbay and South Devon, 30th July 2019
Richard Carlon, Birmingham and Solihull, 22nd July 2019
Rebecca Henry, Manchester West, 17th July 2019
David Jukes, Birmingham and Solihull, 11th July 2019
Hannah Bharaj, Greater Manchester South, 2nd July 2019
Sam Grant, Milton Keynes, 28th June 2019
Alex Blake, London Inner South, 27th June 2019
Marcus McGuire, Birmingham and Solihull, 17th June 2019
Michael Cox, Cornwall & the Isles of Scilly, 13th June 2019
Alistair McDonald, Manchester City, 5th June 2019
Peter Lawrence, Black Country, 3rd June 2019
Sasha Forster, Central Hampshire, 23rd May 2019
Reece Lapina-Amarelle, East Sussex, 25th April 2019
Emily Inglis, Carmarthenshire and Pembrokeshire, 15th April 2019
Nyall Brown, Norfolk, 12th April 2019
Stuart Clark, Exeter and Greater Devon, 2nd April 2019
Anthony Hayward Buckingham, Suffolk, 1st April 2019
George Twiddy, Portsmouth and South East Hampshire, 28th March 2019
Nora Bruton, Birmingham and Solihull, 22nd March 2019
Tamsin Grundy, Norfolk , 13th March 2019
Stephen Harte, Birmingham and Solihull, 13th February 2019
Stephen Kennedy, Birmingham and Solihull, 7th February 2019
Miles Naylor, West Yorkshire, 31st January 2019
Anthony Watson, Birmingham and Solihull, 29th January 2019
David Squire, Black Country, 23rd January 2019
Ellie Long, Norfolk, 16th January 2019
Peter George Garvin, Inner West London, 5th January 2019
Catherine Horton, South London, 14th December 2018
Ruth Ellen Edwards, South Wales Central, 13th December 2018
Henry Williams, West London, 7th November 2018
Eleanor Brabant, Southampton and New Forest, 5th November 2018
Matthew Arkle, Suffolk, 1st November 2018
Karl Cassimjee, Manchester West, 17th October 2018
Trystan Byrant, Plymouth, Torbay and South Devon, 11th October 2018
Sheila Ann Hadfield, South Manchester, 17th September 2018
Terry Bennett, Wiltshire and Swindon, 14th September 2018
Dan Collins, Birminham and Solihull, 31st August 2018
Kelly Campbell, Essex, 8th August 2018
Astonn Mitchell-Male, Manchester North, 25th July 2018
Paul Allan, Inner West London, 19th June 2018
John Hazlewood, Leicester City and Leicestershire South, 13th June 2018
Margaret Stemp, West Sussex, 11th June 2018
Kevin Freely, West London, 7th June 2018
Marcus Hance, Cornwall & the Isles of Scilly, 31st May 2018
John Derwent, South Manchester, 24th May 2018
Caroline Scott, Milton Keynes, 17th May 2018
Grahame Searby, West Yorkshire Western, 15th May 2018
Greg Hutchins, Warwickshire, 2nd May 2018
Lewis Colgan, Buckinghamshire, 30th April 2018
Rosalind Flett, South London, 18th April 2018
Katy Roberts, Inner London South, 12th April 2018
Sara Moran, Blackpool & Fylde, 10th April 2018
Henry Heselton, Surrey, 4th April 2018
Anthony Paine, Liverpool and Wirral, 28th March 2018
Matthew Faulkner, Hertfordshire, 27th March 2018
Martin Tilly, Gloucestershire, 6th March 2018
Rastislav Petrisko, London Inner South, 28th February 2018
Thomas Curtin, Cornwall and the Isles of Scilly, 27th February 2018
Bethany Shipsey, Worcestershire, 14th February 2018
William Lound, Manchester West, 19th January 2018
John Edwards, South Staffordshire, 10th January 2018
Rebecca Romero, Avon, 13th December 2017
Craig Royce, Essex, 12th December 2017
Daniel Watson, North Wales, 8th December 2017
Joshua Hamill, (suicide), 30th November 2017
Wycliffe Matthews, Manchester West, (care home), 27th November 2017
Stephanie Cave, South Wales, (suicide), 16th November 2017
Steven Jones, South Yorkshire, 14th November 2017
Daisy French, (suicide), 8th November 2017
Paul Mullen, Manchester West, 6th November 2017
Ryan Vout, Nottinghamshire, 3rd November 2017
Penelope Benton, Black Country, 31st October 2017
Gordon Penistan, Central Hampshire, 26th October 2017
Christopher Kiernan, South Yorkshire, (suicide), 10th October 2017
Sian Witheridge, Inner North London, (suicide), 10th October 2017
Pamela Craigie, West London, (care home), 27th September 2017
Frances Greenhalgh, Manchester West, (suicide), 7th September 2017
Gillian O'Keefe, London Inner West, (suicide), 5th September 2017
Fallon Abby, Inner North London, (suicide), 7th August 2017
Sharon Halliwell, Manchester West, (suicide), 31st July 2017
Sarah Reed, City of London, (prison - delay in fitness to plead assessment) 30th July 2017
Songul Bozdag, Inner North London, (suicide), 24th July 2017
Carly Gordon, Exeter and Greater Devon, (suicide), 19th July 2017
Edwin O'Donnell, Liverpool, (prison - failures in observation), 16th July 2017
Sofia Legg, Somerset, (suicide), 11th July 2017
Sabrina Walsh, East Sussex, (suicide - failures in observation / CCTV), 6th July 2017
Dean Rowland, Staffordshire South, (suicide - delays in seeing GP), 27th June 2017
Janet Muller, West Sussex, 16th June 2017
Lee Hastings-Swain, Liverpool & Wirral, (suicide - failures in community coordination), 16th June 2017
Andrew Codling, Bedfordshire and Luton, 1st June 2017
Callum Smith, Avon, (prison suicide - various failures), 26th May 2017
Terry Latimer, North Lincolnshire and Grimsby, (suicide - failure to act on earlier safeguarding concern), 25th May 2017
Olaseni Lewis, South London, (police restraint), 9th May 2017
Pippa McManus, Manchester South, 2nd May 2017
Daniel Dunkley, Milton Keynes, (prison suicide - failures in risk assessment and observation), 28th April 2017
Joleen Linton, Coventry, (observation), 24th April 2017
Terence Pimm, Essex, (suicide - police custody), 21st April 2017
Jamie Fairclough, Central and South East Kent, (supported living), 11th April 2017
Luke Moulding, Bedfordshire & Luton, (suicide), 5th April 2017
Daniel Maher, Surrey, (suicide after hospital discharge), 5th April 2017
Kate Dolby, Nottinghamshire, (suicide), 28th March 2017
Grant Richards, East London, (suicide), 20th March 2017
Mariana Pinto, Inner North London, (suicide after hospital release), 13th March 2017
Leah Ratherham, Birmingham and Solihull, (suicide), 13th March 2017
Lester Stacey, Stafford, (suicide), 9th March 2017
Annabel Lewis, Stafford, (suicide), 8th March 2017
James O'Brien, Inner South London, (hospital), 3rd March 2017
Joan Rimmer, Liverpool and Wirral, (care home), 3rd March 2017
Stephen McDermott, Preston and West Lancashire, (suicide), 2nd March 2017
Frederick Bevan, Birmingham and Solihull, (DoLS), 1st March 2017
Abigail Baynham, Black Country, (suicide), 2 7th February 2017
John Haughey, East Riding and Kingston-upon- Hull, (hospital), 10th February 2017
Rachel Morgan, South Manchester, (observation), 9th February 2017
Roger Tombs, Birmingham and Solihull, (DoLS, hospital), 9th February 2017
Derek Lee, City of Brighton and Hove, 6th February 2017
Jack Portland, Buckinghamshire, (supported living), 3rd February 2017
Charlotte Agnew, City of London, (suicide), 31st January 2017
Anna Phillips, Cornwall and the Isle of Scilly, (suicide), 25th January 2017
Dipa Lad, Nottinghamshire, (hospital), 24th January 2017
Dean Saunders, Essex, (prison), 20th January 2017
Demi Williams, Inner North London, (suicide), 16th December 2016
Carol Leesley, South Yorkshire West, (hospital), 9th December 2016
Georgina Lewis, Gwent, (suicide), 8th December 2016
Joyce Crompton, Manchester West, (DoLS), 2nd December 2016
Doris Clarkson, County Durham and Darlington, (hospital/care home), 29th November 2016
Peter Daniel Usher, East London, (suicide after hospitilisation), 29th November 2016
J ohn Atkinson, South Yorkshire, (suicide), 29th November 2016
Thomas Green, Manchester South, (suicide), 29th November 2016
Jaroslaw Rogala, West London, (suicide), 25th November 2016
Martyn Watkins, Avon, (observation), 11th November 2016
Nihad Ousta, West London, (hospital), 25th October 2016
Michaela Thompson, West Yorkshire, (suicide), 19th October 2016
Ivy Atkin, Nottinghamshire, (care home), 13th October 2016
Robert Davidson, Birmingham and Solihull, (care home), 12th October 2016
Anthony McManus, Milton Keynes, (supported living), 7th October 2016
Emma Timbrell, Worcestershire, (suicide), 28th September 2016
Richard Walsh, London Inner South, (prison), 27th September 2016
Victoria Halliday, Leicester City, (suicide), 23rd September 2016
Dr Debrata Sircar, London Inner South, 22nd September 2016
Christopher Brennan, South London, 21st September 2016
Christopher Jones, North Wales, (suicide), 2nd September 2016
Glen Jordan, Black Country, (hospital), 23rd August 2016
John Jones, North London, (hospital), 19th August 2016
Nathan Lowe, City of London, (suicide), 19th August 2016
Nicholas Sullivan, Manchester City, (hospital), 15th August 2016
Thomas Gallagher, Greater Manchester North, (suicide), 11th August 2016
Oliver Ford, Avon, (suicide), 10th August 2016
Michael McMonigle, County Durham, (suicide, absconding from hospital), 8th August 2016
Winston Harris, Birmingham and Solihull, (care home), 3rd August 2016
John Gerard Jones, Avon, (suicide shortly after hospital release), 1st August 2016
Joshua Knox Hooke, Eastern Area Greater London, (suicide, hospital failed to keep watch), 28th July 2016
John Preston, Rutland and North Leicestershire, (suicide), 27th July 2016
Patricia Cleghorn, Birmingham and Solihull, (suicide whilst waiting for a bed), 25th July 2016
Rohan Fitzsimons, Avon, (suicide whilst on leave), 20th July 2016
Michael Williams, Leicester City and Leicestershire South, (prison), 7th July 2016
Beverley Devanney, West Yorkshire Western, (suicide), 20th June 2016
Anielka Jennings, Gloucestershire, (suicide), 15th June 2016
Edward Mallen, Cambridgshire and Peterborough, (suicide), 14th June 2016
Christina O'Brien, London South, (suicide), 7th June 2016
Kevin Dermott, Cheshire, (prison), 7th June 2016
Amy El-Keria, West Sussex, (observation/resusitation), 1st June 2016
Danielle Robinson, North Wales, (hospital), 25th May 2016
Jessica Birkhead, Exeter and Greater Devon, (overdose), 20th May 2016
Simon Klineberg, Cornwall and the Isle of Scilly, (overdose), 19th May 2016
Tracey Lynch, Blackburn, Hyndburn and Ribble Valley, (rehabilitation unit), 19th May 2016
Louise Turner (also known as Abigail Jackson), Exeter and Great Devon, (suicide), 16th May 2016
Samuel Carroll, Western area North Yorkshire, (Suicide), 5th May 2016
Gillian Taylor, South Wales Central, (suicide, CMHT), 29th April 2016
Komang Jack Susianta, North London, (drugs), 29th April 2016
Mihangel ap Dafydd, Carmarthenshire and Pembrokeshire, (hospital), 29th April 2016
Ian Brown, Milton Keynes, (prison), 26th April 2016
Margaret Rogerson, Manchester West, (DoLS), 20th April 2016
Marjorie Wood, Manchester South, (DoLS), 18th April 2016
Luke Ayres, Birmingham and Solihull, (hospital), 15th April 2016
Doreen Mattinson, North London, (DoLS), 14th April 2016
Steven Murphy, Portsmouth and South East Hampshire, (suicide, absconded from hospital), 12th April 2016
Adele Blakeman, Manchester South, (suicide), 29th March 2016
Hannah Evans, Cheshire, 11th March 2016
Benjamin Brown, Northern District of Greater London, (observation), 10th March 2016
Philmore Mills, Berkshire, (restraint), 8th March 2016
Helen England, Manchester West, (suicide), 7th March 2016
William Higgleton, East London, (overdose), 1st March 2016
Carole Lovett, Northern District Greater London, (hospital), 22nd February 2016
Brenda Morris, Inner North London, (suicide whilst on leave), 19th February 2016
Lorraine Youngs, Norfolk, (hospital), 27th January 2016
Sally Mays, East Riding of Yorkshire and Kingston upon Hull, 23rd October 2015
Connor Sparrowhawk, Oxfordshire, 16th October 2015
Francesca Whyatt, West London, 3rd September 2015
Julia Hayward, Surrey, 11th August 2015
Simon Reynolds, Avon, 15th July 2015
Dorothy McDermott, Manchester North, 10th July 2015
Phyllis Broomhead, South Yorkshire, 6th July 2015
David Knight, Cornwall and the Isle of Scilly, 17th June 2015
Matthew Groom, Inner North London, 15th June 2015
Kingsley Burrell, Birmingham and Solihull, 15th May 2015
William Thompson, Inner North London, 30th April 2015
Sara Green, Manchester South, 28th April 2015
Tamara Holboll, North London, 20th April 2015
Leah Levine, South Manchester, 27th February 2015
Kesia Leatherbarrow, Manchester South, 6th February 2015
Rafal Delezuch, Leicester City and South Leicestershire, 23rd January 2015
Dale Proverbs, Northern District of Greater London, 8th December 2014
Rebecca Louise Overy, Nottinghamshire, 27th November 2014
John Ioannou, Northern District of Greater London, 21st November 2014
Sandra Bodrozic, Inner North London, 17th November 2014
Mary Stroman, Wiltshire and Swindon, 16th October 2014
Donna Kirkland, Coventry and Warwickshire, 24th July 2014
Peter Franklin, Mid Kent and Medway, 30th April 2014
Andrew Cairns, Derby & Derbyshire, 22nd October 2013
Michael Sweeney, North London, 18th September 2013
Kerrie Wooltorton, Report of inquest, 28th September 2009
DSA archive