PFD Response Tracker

Prevention of Future Deaths

Total: 1,424 Responded: 0 No identified response (past 2 years): 0 Pending: 0 Historic with no identified response: 1,424

How statuses are calculated — 56-day deadline, Judiciary.UK data

Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date. We rely on Judiciary.UK for response data, so if a response has been provided but not yet published there, it may show incorrectly here. "No identified response", "Pending", and "Historic" only count reports where no response at all has been identified as published on Judiciary.UK. If at least one response has been published for a report, it counts as "Responded" — even if not every listed addressee has a separate published response. This is because addressee data from Judiciary.UK can be unreliable: address fragments, job titles, and redacted names are sometimes parsed as separate addressees, and a single response PDF may cover multiple parties. "Historic with no identified response" means we have not been able to identify a published response, but the report is more than two years old. We do not mark these as overdue or pending because older reports may well have received a response that was simply never made public. This is a neutral status indicating absence of an identified published record, not confirmed non-compliance.

2 reports include a non-response confirmed by the Chief Coroner. Show only confirmed

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1,424 reports · Page 10 of 29

Date	Deceased	Addressee(s)	Status	Responses
27 Dec 2018	Kenneth Bardsley The coroner raises concerns regarding the lack of minimum qualification standards for lift engineers, the absence of an …	Care Quality Commission Department for Work and Pensions Health and Safety Executive Lancs & Cumbria Lifts UK … Serendipity Care Home	Historic (No Identified Response)	0/5
24 Dec 2018	Joyce Long The provided text is incomplete and does not detail any specific concerns regarding future deaths related to patient …	Buckinghamshire Healthcare NHS Trust South Central Ambulance Service	Historic (No Identified Response)	0/2
21 Dec 2018	William Atherton Failure of medical review, unrecognised worsening condition, missing nursing observations, and incorrect, inconsistently applied Early Warning Scores prevented …	Queen Elizabeth Hospital	Historic (No Identified Response)	0/1
21 Dec 2018	Cady Stewart Opiate medication from a deceased parent on palliative care was not removed by nursing staff, remaining accessible and …	Tameside Clinical Commissioning Group	Historic (No Identified Response)	0/1
21 Dec 2018	Mihaela Lazar Inadequate fire detection and warning systems, including missing smoke alarms and kitchen doors, combined with unacceptable escape routes …	National Fire Chiefs	Historic (No Identified Response)	0/1
21 Dec 2018	Dorina Zangari Undermined fire safety measures, absent functioning fire detection, and an inadequate alternative escape route in maisonettes place residents …	Local Government Association London Borough of Barking & … London Councils National Fire Chiefs National Housing Federation National Landlords Association MHCLG West Midlands Fire Service	Historic (No Identified Response)	0/8
18 Dec 2018	Natalie Hunter The Isle of Wight NHS Trust frequently fails to provide timely discharge summaries to GPs, hindering continuous patient …	St Mary’s Hospital NHS Trust	Historic (No Identified Response)	0/1
11 Dec 2018	John Mayhew Clarification, redrafting, and improved guidance are needed for the PSI64/2011 section on first case reviews of ACCT assessments …	HM Inspector of Prisons Independent Advisory Panel on Deaths … National Offender Management Service	Historic (No Identified Response)	0/3
28 Nov 2018	Ronald Houchin Falls risk assessments were not consistently followed, resulting in inadequate assistance and supervision for mobilising, and multiple preventable …	Rosehill House Care Home	Historic (No Identified Response)	0/1
28 Nov 2018	Michelle Roach GP's knowledge of VTE symptoms and record-keeping were inadequate. The GP practice lacked a robust system for learning …	Royal Berkshire Hospital Waterfield Practice	Historic (No Identified Response)	0/2
21 Nov 2018	Ben Walmsley The school's IT system lacked a mechanism to alert staff when students attempted to access blocked self-harm content, …	Department for Education	Historic (No Identified Response)	0/1
21 Nov 2018	Roy Burgess The hospital's Early Warning System was not adhered to, leading to missed senior medical reviews. Inadequate and non-chronological …	Department of Health and Social … Doncaster Bassetlaw Teaching Hospital	Historic (No Identified Response)	0/2
20 Nov 2018	Austin Thomas Drivers of heavy machinery could be distracted by high-volume music, lacking a specific policy. The drug policy was …	Haulage Contractors Limited	Historic (No Identified Response)	0/1
16 Nov 2018	Emmett Gillah Discharge letters lacked detail for GPs, KMPT failed to maintain post-discharge contact as per policy, and communication with …	Kent and Medway NHS Social …	Historic (No Identified Response)	0/1
16 Nov 2018	Eleanor Brabant Observation policies for vulnerable patients were unclear, staff lacked training on safeguarding and reporting crimes, and nurses misunderstood …	Southern Health NHS Trust	Historic (No Identified Response)	0/1
16 Nov 2018	Sheila Graham Prolonged social isolation for a patient with C. difficile negatively impacted her well-being, compounded by inadequate nutritional information …	Midlands Partnership NHS Trust	Historic (No Identified Response)	0/1
12 Nov 2018	Joseph Page Hospital policies for storing patients' own medication were breached, allowing a patient unsupervised access to prescription drugs which …	Cardiff & Vale University Health …	Historic (No Identified Response)	0/1
6 Nov 2018	Ryan Williams Unsupervised, unmanned stations pose a risk, as vulnerable individuals can remain on premises for extended periods without any …	Network Rail	Historic (No Identified Response)	0/1
5 Nov 2018	Gareth Jones The road surface quality was below Highways Agency standards for three years, likely contributing to the death. This …	Worcestershire County Council	Historic (No Identified Response)	0/1
5 Nov 2018	Daniel Stokes Prison healthcare staff possessed diazepam but were not trained or authorised to administer it, potentially hindering response to …	NHS England	Historic (No Identified Response)	0/1
4 Nov 2018	Patricia Chambers Concerns were identified regarding practices at West London Mental Health Trust, indicating a risk of future deaths if …	Shepherds Bush Medical Centre West London Mental Health Trust	Historic (No Identified Response)	0/2
2 Nov 2018	Karl Cassimjee	Greater Manchester Mental Health NHS … Manchester Royal Infirmary	Historic (No Identified Response)	0/2
1 Nov 2018	Colette Dunn A full Mental Health Act assessment was omitted before discharge despite police concerns. A lack of clear discharge …	Milton Keynes Clinical Commissioning Group	Historic (No Identified Response)	0/1
25 Oct 2018	Andrea Franzosi Inadequate supervision of junior doctors on wards, specifically regarding patient discharges occurring without examination by a senior practitioner.	Gloucestershire NHS Trust	Historic (No Identified Response)	0/1
24 Oct 2018	Catherine Gibbon Significant safety failures included inadequate health pledge guidance, untrained staff for medical conditions, insufficient CCTV monitoring with a …	DW Fitness First UK Active	Historic (No Identified Response)	0/2
23 Oct 2018	Allan Shepard Response times for falls were missed due to inadequate staffing with one-person responder units, and crucial updated patient …	City Wide Alarms Sheffield City Council	Historic (No Identified Response)	0/2
19 Oct 2018	Robert McLoughlin The jury identified errors and omissions in the care of an HMP Leeds inmate, which potentially contributed to …	HMPPS	Historic (No Identified Response)	0/1
19 Oct 2018	John Lee A clerical error severely delayed an urgent vascular appointment, changing an elective procedure to an emergency and contributing …	Medway NHS Trust	Historic (No Identified Response)	0/1
18 Oct 2018	Anne Roberts Inadequate training for bank staff on choking risks, poor dissemination of this information in patient records, and difficulties …	NHS Professionals Limited Prospect Park Hospital	Historic (No Identified Response)	0/2
18 Oct 2018	Joseph Grantham Key concerns include significant delays in discharge paperwork and specialist letters, unclear care responsibility, missing patient notes, inadequate …	Department of Health and Social … Healthcare Safety Investigation Branch Manchester University NHS Foundation Trust	Historic (No Identified Response)	0/3
11 Oct 2018	Thomas Lear A released prisoner was offered no accommodation support, and urgent suicide threats sent to his offender manager's mobile …	Staffordshire Police Ministry of Justice	Historic (No Identified Response)	0/2
9 Oct 2018	Tom Cribley Repeated systemic failings included poor documentation, delayed escalation of patient deterioration and NMEWS, inadequate clinical handovers, and delayed …	Aintree University Hospital NHS Trust Care Quality Commission General Medical Council NHS England NHS South Sefton Clinical Commissioning … Nursing and Midwifery Council Public Health England	Historic (No Identified Response)	0/7
3 Oct 2018	Brian Frost Unsafe living conditions, specifically loose flooring, were unaddressed in a frail, elderly priest's accommodation, as diocesan welfare visits …	Diocese of Westminster the Roman Catholic Church of … Patrick Stead Hospital	Historic (No Identified Response)	0/3
19 Sep 2018	Grenfell Tower No structured health screening programme is in place for individuals impacted by the Grenfell Tower incident, risking unaddressed …	NHS England	Historic (No Identified Response)	0/1
14 Sep 2018	Daniel Collins A mental health service transferred a recently suicidal patient's care, requiring the patient to initiate contact with the …	Birmingham and Solihull Clinical Commissioning … Birmingham Women’s and Children’s NHS …	Historic (No Identified Response)	0/2
13 Sep 2018	Laila Habibi and Daniel Ghafuri A dangerous diversion road with a history of fatalities lacked crucial 'single carriageway' warning signs, and sat navs …	Warwickshire County Council	Historic (No Identified Response)	0/1
12 Sep 2018	Greg Hutchins Mental health telephone triage was undocumented and unrecorded, with no system for rapid information sharing for out-of-area patients, …	Birmingham & Solihull Mental Health …	Historic (No Identified Response)	0/1
10 Sep 2018	Darren Urquhart Inadequate railway anti-trespass measures, including poor trespass mat placement, missing platform gates, and insufficient fencing, create a risk …	Network Rail	Historic (No Identified Response)	0/1
10 Sep 2018	Gladys Williams Ongoing, multifactorial problems with ambulance delays, emergency department overcrowding, and patient flow continue to risk lives, despite previous …	Betsi Cadwaladr University Health Board Welsh Ambulance Services	Historic (No Identified Response)	0/2
7 Sep 2018	Scott Carton Inadequate psychological support for prisoners with mental health and drug issues upon release, including unsuitable hostel placements without …	MOJ National Probation Service	Historic (No Identified Response)	0/2
3 Sep 2018	Doris Douthwaite Vulnerable residents with dementia were left unsupervised due to unclear policies, an ambiguous falls risk assessment tool, and …	HC-One	Historic (No Identified Response)	0/1
24 Aug 2018	Jacqueline Jordan The absence of a central reservation barrier along a specific stretch of dual carriageway allows pedestrian shortcuts, posing …	Bristol City Council	Historic (No Identified Response)	0/1
19 Aug 2018	David Sweeney A call to the London Ambulance Service regarding an unconscious man did not prompt a red prioritisation, raising …	London Ambulance Service NHS Trust	Historic (No Identified Response)	0/1
9 Aug 2018	Kelly Campbell Concerns exist regarding the lack of rigorous trust policies for returning items like shoelaces and the dreary, unstimulating …	Essex Partnership University NHS Foundation …	Historic (No Identified Response)	0/1
1 Aug 2018	Cuthbert Hingert Significant medication errors, including duplicate prescribing and incorrect dosages, occurred due to clinicians failing to check databases and …	Isle of Wight NHS Trust	Historic (No Identified Response)	0/1
1 Aug 2018	Nigel Handscomb Incomplete and inaccurate GP consultation notes, made several hours after the fact, failed to record critical patient information, …	Eden Park Surgery	Historic (No Identified Response)	0/1
27 Jul 2018	Natalie Billingham Inadequate communication, delayed assessment of blood results, and missed opportunities for early antibiotic administration led to a failure …	Care Quality Commission Russell Hall Hospital	Historic (No Identified Response)	0/2
26 Jul 2018	Astonn Mitchell-Male The Trust lacks a policy for patient medication monitoring and triangulation of information in community settings, compounded by …	Pennine Care NHS Trust	Historic (No Identified Response)	0/1
25 Jul 2018	Jane Parker Care home staff had poor understanding of modified diets and lacked systems for correct food preparation and marking. …	Care Quality Commission Minister of State for Care	Historic (No Identified Response)	0/2
25 Jul 2018	Robert Wrinch The pathology department lacked systems for tracking samples and documenting clinician communications, causing delays and unclear chronologies. Incompatible …	Department for Health Greater Manchester Strategic Health Group Royal College of Pathologists Stockport NHS Trust	Historic (No Identified Response)	0/4

Kenneth Bardsley