MJB ADHD · Static reading view · Interactive version
Status: drafted · Content checked 2026-10-07
Coroners' Prevention of Future Deaths reports where untreated ADHD or access to treatment formed part of the coroner's concern — verified against the reports themselves.
When a coroner believes action could prevent future deaths, they must write a Prevention of Future Deaths report, and the recipient must reply within 56 days. These reports are public. They are written about one person's death, with care, and are summarised here with the same care.
The expanded case register contains 13 source-linked records: deaths and one living person’s serious-harm case. It identifies formal reports, government reviews and attributed INQUEST archive accounts. Each entry has its care context, findings, response and remaining record questions.
Oliver Winson died aged 33 after four years on an adult ADHD waiting list. The Norfolk coroner's report to NHS England raised concern that people identified as at risk from untreated ADHD remain on long waiting lists without treatment or monitoring, while evidence also noted a medication shortage for those already diagnosed.
COR-2024-0699-WINSONA prevention report records concerns. Some inquests also make explicit findings that neglect or aftercare failures contributed to a death; where present, those findings are stated directly. These reports show that the risks discussed elsewhere in this guide have been recognised by coroners — they do not provide rates.
Coroners' reports cover only deaths that reach inquest and in which the coroner chose to report; they are not a count.
The register is not exhaustive. Original audio and later evidence of implementation require their own verification.