Prevention of future deaths report
Dated 22 Jun 2026, from the coroner for Devon, Plymouth and Torbay. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedOrganisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated22 Jun 2026
- Deadline17 Aug 2026
- Published on judiciary.uk21 Aug 2026
- Today22 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| NHS England | Response publishedPublished on judiciary.uk in August 2026. |
The coroner’s concerns
Read the coroner’s concerns in the full report on judiciary.uk.
Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2026-0289
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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