View source for Inquests - Prevention of Future Deaths reports

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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,Â 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
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