37 Prevention of Future Deaths reports name this organisation, 2013–2026. Every report below links to the original on judiciary.uk.
29 of 37 reports (78%) have at least one response published on judiciary.uk.
For reports written in the same years, 77% 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 | Deceased | Category | Coroner | Response | |
|---|---|---|---|---|---|
| 24 Mar 2026 | Robert Day | Suicide (from 2015) | Ian Potter | Home Office, DHSC Department for Womens Health and Mental Health, Kent and Medway Mental Health NHS Trust | source |
| 1 Feb 2026 | Simon Moss | Suicide (from 2015) | Xavier Mooyaart | NHS England | source |
| 25 Nov 2025 | Andrew McCleary | Alcohol, drug and medication relation death | Police related death | Community health care and emergency services related deaths | Emma Whitting | Bedfordshire Police | source |
| 15 Oct 2025 | Tony Duncan | Suicide (from 2015) | Mental Health related deaths | Alison Hewitt | South London and Maudsley NHS Foundation Trust | source |
| 19 Sep 2025 | Luke Chatterton | Alcohol, drug and medication related death | Andrew Harris | none published | source |
| 7 Apr 2025 | Christopher McDonald | Mental Health related deaths | Suicide (from 2015) | Sian Reeves | South London and Maudsley NHS Foundation Trust | source |
| 25 Oct 2024 | Michael Crane | Police related deaths | Mental Health related deaths | Care Home Health related deaths | Ian Potter | Metropolitan Police Service, Prime Life | source |
| 27 Jun 2024 | Emily Collishaw | Alcohol, drug and medication related deaths | Andrew Harris | NHS England, Ministry of Housing Communities Local Governments, DHSC | source |
| 10 Jun 2024 | Sailor Court | Suicide (from 2015) | Child Death (from 2015) | Sebastian Naughton | NHS England, DHSC | source |
| 17 May 2024 | Jada Monoja | Suicide (from 2015) | Xavier Mooyaart | DHSC, NHS England, South London and Maudsley NHS Trust | source |
| 25 Mar 2024 | Jacqueline Cobain | Railway related deaths | Suicide (from 2015) | Michelle Haste | South London and Maudsley NHS Foundation Trust | source |
| 26 May 2023 | Conrad Colson | Suicide (from 2015) | Nadia Persaud | NHS England, South London and Maudsley NHS Foundation Trust, Aesthetic Dermatology, NELFT | source |
| 24 Apr 2023 | Samuel Howes | Child Death (from 2015) | Suicide (from 2015) | Railway related deaths | John Taylor | Department of Health and Social Care, NHS England 1 | source |
| 18 Apr 2023 | Patrick Soames | Suicide (from 2015) | Edmund Gritt | none published | source |
| 28 May 2022 | Hayley Smith | Other related deaths | Catherine Wood | none published | source |
| 18 Aug 2020 | Viktor Scott-Brown | Suicide; Community healthcare related deaths | Oliver Longstaff | Oxleas NHS Foundation Trust, Tees Esk and Wear Valleys NHS Foundation Trust Redacted 1, BNF Publications, NICE | source |
| 10 Feb 2020 | Kerry Aldridge | Railway related deaths; Suicide (from 2015); Mental Health related deaths | Andrew Harris | South London and Maudsley NHS Foundation | source |
| 24 Sep 2019 | Rebecca Marshall | Hospital Death (Clinical Procedures and medical management) related deaths; Suicide (from 2015) | Briony Ballard | Kent and Medway NHS Trust | source |
| 29 Jul 2019 | Alex Blake | Alcohol, drug and medication related deaths; Hospital Death (Clinical Procedures and medical management) related deaths | Andrew Harris | NHS Professionals Redacted 1, NMC | source |
| 15 Jan 2019 | Catherine Horton | Mental Health related deaths | Sarah Ormond-Walshe | Metropolitan Police | source |
| 5 Nov 2018 | REDACTED | Community health care | Suicide (from 2015) | Henrietta Hill QC | GMC to Prevention of future deaths report | source |
| 24 May 2018 | Rosalind Flett | Mental Health related deaths | Selena Lynch | none published | source |
| 8 May 2018 | William Dickens | Hospital Death (Clinical Procedures and medical management) related deaths | Henrietta Hill QC | South London Maudsley NHS Trust | source |
| 27 Apr 2018 | Katy Roberts | Hospital Death (Clinical Procedures and medical management) related deaths; Child Death (from 2015) | L Tagliavini | South London and Maudsley | 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 |
| 28 Jun 2017 | Olaseni Lewis | Hospital Death (Clinical Procedures and medical management) related deaths; Police related deaths | Selena Lynch | Metropolitan Police, South London and Maudsley NHS Trust | source |
| 31 May 2017 | Jonathan Palmer | State Custody related deaths | Kevin McLoughlin | HM Prison Probation Service | source |
| 28 May 2017 | Jamie Pashley | Hospital Death (Clinical Procedures and medical management) related deaths | Julian Morris | Kings College Hospital NHS Trust | source |
| 5 Dec 2016 | Christopher Brennan | Child Death (from 2015); Hospital Death (Clinical Procedures and medical management) related deaths | Selena Lynch | none published | source |
| 14 Jun 2016 | Christina O’Brien | Mental Health related deaths; Suicide (from 2015) | Christopher Williams | none published | source |
| 20 Jan 2016 | Faiza Ahmed | Emergency Services related deaths | Mental Health related deaths | Mary Hassell | the Department of work and Pensions, the Metropolitan Police, the London Ambulance Service | source |
| 9 Jul 2015 | Michael George | Hospital Death (Clinical Procedures and medical management) related deaths | Andrew Harris | South London and Maudsley NHS Trust | source |
| 31 Oct 2014 | Christopher Ajayi | Community health care and emergency services related deaths | Hospital Death (Clinical Procedures and medical management) related deaths | Sarah Ormond-Walshe | Sunrise Senior Living, South London and Maudsley NHS Trust | source |
| 6 Mar 2014 | Natasha Raghoo | Hospital Death (Clinical Procedures and medical management) related deaths | David Skipp | Partnership in Care | source |
| 20 Aug 2013 | Nicola Matthews | Mental Health related deaths | Dr R N Palmer | none published | source |
| date unknown | Mina Topley-Bird | Hospital Death (Clinical Procedures and medical management) related deaths | Mental Health related deaths | Suicide (from 2015) | James Thompson | West Park Hospital, Dept. of Health and Social Care | source |
| 24/04/26 | Edward Muwanga | Paul Rogers | none published | 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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