PFD Response Tracker
Prevention of Future DeathsHow 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.
39 reports
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a non-response confirmed by the Chief Coroner.
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6,254 reports
· Page 100 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 28 Jan 2016 |
Ronald Volante
Call handlers failed to use medical history to inform ambulance services and were not trained to report changes …
|
Magenta Living Support Link | All Responded | 1/1 |
| 28 Jan 2016 |
Antony Briggs
Incompatible hospital IT systems prevented urologists from accessing patient test results, leading to a dangerous gap in follow-up …
|
Stockport NHS Foundation Trust | All Responded | 1/1 |
| 28 Jan 2016 |
Andrew Coates
An unsuitable wooden shed was licensed for fireworks storage, containing other combustibles and having deficient licensing that failed …
|
Cumbria County Council | All Responded | 1/1 |
| 27 Jan 2016 |
Joanna Bowring
Carers were excluded from risk assessment processes and not advised on suicide risk behaviours, while the patient left …
|
Kent and Medway NHS and … | All Responded | 1/1 |
| 26 Jan 2016 |
Rio Andrew
The regulation of private medical companies at events is inadequate, creating false security and leaving event medical provision, …
|
Department of Health and Social … Lifeskills | All Responded | 2/2 |
| 22 Jan 2016 |
Darren Wakefield
The report highlights a national safety issue and requests confirmation that IPCC recommendations have been followed, implying a …
|
National Police Chiefs’ Council | All Responded | 1/1 |
| 22 Jan 2016 |
Javaid Iqbal
Charcoal packaging warnings about indoor use lack prominence and do not explicitly highlight the risk of death from …
|
Tesco Store PLC | Historic (No Identified Response) | 0/1 |
| 21 Jan 2016 |
Alice Dickenson
The GP referral form for rapid access endoscopy is limited, potentially leading to the omission of critical past …
|
Kent and Medway Cancer Collaborative | Historic (No Identified Response) | 0/1 |
| 21 Jan 2016 |
Leslie Murray
Insufficient staffing on hospital wards prevents essential one-to-one patient care, leading to preventable falls and other critical care …
|
St George’s Hospital | Historic (No Identified Response) | 0/1 |
| 21 Jan 2016 |
Elvis Snelson
The "legal high" acetylfentanyl, a highly potent opioid, poses significant risks due to users being unaware of its …
|
Department of Health and Social … | Historic (No Identified Response) | 0/1 |
| 20 Jan 2016 |
Derek Hare
The use of two separate patient note systems caused confusion and errors, and repeated denials of hospital appointments …
|
Tameside Hospital NHS Trust | All Responded | 1/1 |
| 20 Jan 2016 |
Leslie Summerfield
The withdrawal of urgent endoscopy services at a hospital, despite available resources, forces critically ill patients to be …
|
Central Manchester NHS Trust | Historic (No Identified Response) | 0/1 |
| 20 Jan 2016 |
Faiza Ahmed
No specific concerns are detailed in the provided text, which refers only to the jury's determination.
|
Department for Work and Pensions London Ambulance Service NHS Trust Metropolitan Police | All Responded | 3/3 |
| 20 Jan 2016 |
Steven Rogers
A doctor discharged a patient without seeing them, indicating a fundamental lack of understanding of discharge importance, and …
|
Stockport NHS Foundation Trust | All Responded | 1/1 |
| 19 Jan 2016 |
Lee Rushton
There is a lack of clear policy and training regarding how ACCT care plans and mandatory reviews should …
|
Unknown | 0/0 | |
| 19 Jan 2016 |
Irene Pearson
Matrifen patch warnings about hot baths are obscure and vague, and dangerous advice was given to use baths …
|
Takeda UK Ltd Macmillan Cancer Support Churchgate Surgery | Partially Responded | 2/3 |
| 18 Jan 2016 |
Norah Fairhurst
Older large goods vehicles, not mandated to have Class VI "cyclops" mirrors, have a dangerous blind spot directly …
|
Department for Transport | All Responded | 1/1 |
| 15 Jan 2016 |
Jasmine Lapsley
Emergency services in rural NW Wales suffer from a lack of nighttime air support, ineffective rostering and communication …
|
Welsh Ambulance NHS Trust Welsh Assembly Government | All Responded | 2/2 |
| 14 Jan 2016 |
Lee Rigby
Systemic failures in care provision include support workers lacking keys, leaving residents unsupervised, and inadequate staffing levels, training, …
|
United Response | Historic (No Identified Response) | 0/1 |
| 13 Jan 2016 |
Arenijus Nedzelskies
Specific synthetic cannabinoid receptor agonists (5F AKB-48, 5F PB-22) are not controlled substances, and the deceased's chronic misuse …
|
Home Office Driver and Vehicle Licensing Agency | Partially Responded | 1/2 |
| 12 Jan 2016 |
Anne Scott
Community care providers lacked training to correctly interpret and act upon data from health monitoring devices, and county-wide …
|
Cornwall and Isles of Scilly … | Historic (No Identified Response) | 0/1 |
| 11 Jan 2016 |
Colin Williams
A client with complex health and social needs, exacerbated by alcoholism, experienced "agency blindness" and lacked consistent support …
|
Cornwall Council Local Adult Safeguarding … | Historic (No Identified Response) | 0/1 |
| 11 Jan 2016 |
Emily Milligan
The increased speed and power of modern power boat leisure craft introduce additional risks, requiring greater awareness from …
|
British Maritime Federation Royal Yachting Association | Historic (No Identified Response) | 0/2 |
| 11 Jan 2016 |
Robin Brett
A missed steroid dose went unnoticed due to a lack of system alerts on both paper and electronic …
|
Great Western Hospital NHS Foundation … | Historic (No Identified Response) | 0/1 |
| 11 Jan 2016 | Nicholas Milligan | British Maritime Federation Royal Yachting Association | Historic (No Identified Response) | 0/2 |
| 8 Jan 2016 |
Stefen Boswell
Inconsistent police pursuit policies between local and national guidelines on wrong-way driving, coupled with inadequate communication systems for …
|
West Mercia Police | All Responded | 1/1 |
| 8 Jan 2016 |
Norman Dorn
Cornwall care homes may lack adequate or updated policies for recognising and confirming death and for resuscitation, with …
|
Care Quality Commission Cornwall and Isles of Scilly … | Historic (No Identified Response) | 0/2 |
| 7 Jan 2016 |
Joanne French
Early patient discharge was hampered by unclear assessment requirements, a failure to include family input in decision-making, and …
|
Sussex Partnership NHS Trust | Historic (No Identified Response) | 0/1 |
| 4 Jan 2016 |
Thomas Burchell
Inadequate and incomplete medical and nursing record-keeping, particularly a poorly maintained seizure chart, failed to accurately document a …
|
Hospital NHS Trust Derriford Hospital Borchardt Medical Centre | Partially Responded | 1/2 |
| 4 Jan 2016 |
Mark Holdsworth
Police failed to communicate critical information about the deceased's recent suicide threat to arresting officers and custody staff, …
|
Lincolnshire Police | Historic (No Identified Response) | 0/1 |
| 4 Jan 2016 | Matthew Wood | Department for Transport London Heliport Civil Aviation Authority | Partially Responded | 2/3 |
| 4 Jan 2016 |
Peter Barnes
Inadequate planning policies for tall buildings around the London Heliport fail to ensure safety, lacking in-depth consultation with …
|
London Heliport Civil Aviation Authority Department for Transport | Partially Responded | 2/3 |
| 4 Jan 2016 |
Gary Peel
The need for deterrent measures on viaduct walls should be reviewed to prevent future deaths from individuals jumping.
|
Unknown | 0/0 | |
| 31 Dec 2015 |
Margaret Pegnall
A GP practice had a vague domestic abuse flowchart focused on depression, lacked a specific domestic abuse questionnaire, …
|
Unknown | 0/0 | |
| 30 Dec 2015 |
Mollie Bentham
Repeated family concerns about abdominal pain and rising infection markers were not documented, escalated to medical teams, or …
|
Unknown | 0/0 | |
| 29 Dec 2015 | Imran Douglas | London Borough of Tower Hamlets General Medical Council National Offender Management Service | All Responded | 3/3 |
| 24 Dec 2015 |
Angela Brealey
The trust lacked clear procedures for handling third-party information, showed minimal multidisciplinary team involvement in patient care, and …
|
South Staffordshire and Shropshire NHS … St George’s Hospital | Partially Responded | 1/2 |
| 24 Dec 2015 |
Christopher Higgins
Inconsistent mental health observation practices, inadequate patient escort protocols during police transfers, unassessed safety risks in the environment, …
|
James Paget University Hospital Norfolk and Norwich University Hospital Norfolk and Suffolk NHS Foundation … Queen Elizabeth Hospital | All Responded | 3/4 |
| 22 Dec 2015 |
Shalini Ganesh-Ram
Delayed diagnosis of a caecum perforation due to multiple systemic failures, including overlooked warning signs, delayed CT scans, …
|
Royal London Hospital | Historic (No Identified Response) | 0/1 |
| 21 Dec 2015 |
Kay Sheard
Pulse oximeter alarm settings are fixed at a routine level rather than being adjusted to individual patient baselines, …
|
Unknown | 0/0 | |
| 21 Dec 2015 |
Mary Hollands
The system for providing radiologist reports to the Emergency Department is unreliable, creating a risk that subtle injuries …
|
Unknown | 0/0 | |
| 17 Dec 2015 |
James Graham
Critical communication failures between primary care and podiatry, coupled with a lack of ownership in referral processes and …
|
Unknown | 0/0 | |
| 17 Dec 2015 |
Edna Cleaton
The practice lacked systems for regular medical reviews of patients on citalopram, resulting in a three-year delay in …
|
Unknown | 0/0 | |
| 16 Dec 2015 |
William Driscoll
There are serious deficiencies in the medical assessment process for drivers, including insufficient investigation of health conditions, leading …
|
Unknown | 0/0 | |
| 15 Dec 2015 |
Ruth Smith
There were significant delays in doctor review, inadequate nursing observations, and poor record-keeping by both nursing and medical …
|
Unknown | 0/0 | |
| 15 Dec 2015 |
Derek Thomas
Prison reception procedures failed under extreme pressure, leading to suicide risk information being overlooked due to staffing issues. …
|
National Offender Management Service HMP Durham G4S GEOAmey | All Responded | 4/4 |
| 15 Dec 2015 |
Joyce Tozer
Omnipaque is frequently administered at doses exceeding manufacturer's guidelines, sometimes via central lines, which exposes interventional radiology patients …
|
Unknown | 0/0 | |
| 15 Dec 2015 |
Kamrul Rubel
The gym did not enforce the use of the emergency stop cord despite providing advice, raising concerns about …
|
Unknown | 0/0 | |
| 14 Dec 2015 |
William Maskell
The absence of clear protocols and an overemphasis on student autonomy led to delayed intervention and reluctance to …
|
Unknown | 0/0 | |
| 14 Dec 2015 |
Paul Whitehead
Emergency response procedures were inefficient, with delays in contacting emergency services, inadequate first aid provision, and difficulties for …
|
Unknown | 0/0 |
Ronald Volante
All Responded
Call handlers failed to use medical history to inform ambulance services and were not trained to report changes in patient presentation, indicating a need to …
Magenta Living Support Link
Antony Briggs
All Responded
Incompatible hospital IT systems prevented urologists from accessing patient test results, leading to a dangerous gap in follow-up when local GPs failed to act on …
Stockport NHS Foundation Trust
Andrew Coates
All Responded
An unsuitable wooden shed was licensed for fireworks storage, containing other combustibles and having deficient licensing that failed to specify types or designate a specific …
Cumbria County Council
Joanna Bowring
All Responded
Carers were excluded from risk assessment processes and not advised on suicide risk behaviours, while the patient left an initial assessment without a clear understanding …
Kent and Medway NHS …
Rio Andrew
All Responded
The regulation of private medical companies at events is inadequate, creating false security and leaving event medical provision, including "ambulance technicians," largely unregulated, with insufficient …
Department of Health and …
Lifeskills
Darren Wakefield
All Responded
The report highlights a national safety issue and requests confirmation that IPCC recommendations have been followed, implying a potential gap in implementing or verifying crucial …
National Police Chiefs’ Council
Javaid Iqbal
Historic (No Identified Response)
Charcoal packaging warnings about indoor use lack prominence and do not explicitly highlight the risk of death from carbon monoxide poisoning.
Tesco Store PLC
Alice Dickenson
Historic (No Identified Response)
The GP referral form for rapid access endoscopy is limited, potentially leading to the omission of critical past medical history that would assist endoscopists.
Kent and Medway Cancer …
Leslie Murray
Historic (No Identified Response)
Insufficient staffing on hospital wards prevents essential one-to-one patient care, leading to preventable falls and other critical care deficiencies that may contribute to patient deaths.
St George’s Hospital
Elvis Snelson
Historic (No Identified Response)
The "legal high" acetylfentanyl, a highly potent opioid, poses significant risks due to users being unaware of its opioid nature, leading to dangerous sedation and …
Department of Health and …
Derek Hare
All Responded
The use of two separate patient note systems caused confusion and errors, and repeated denials of hospital appointments led to a significantly delayed diagnosis of …
Tameside Hospital NHS Trust
Leslie Summerfield
Historic (No Identified Response)
The withdrawal of urgent endoscopy services at a hospital, despite available resources, forces critically ill patients to be transported, causing unnecessary discomfort and potentially aggravating …
Central Manchester NHS Trust
Faiza Ahmed
All Responded
No specific concerns are detailed in the provided text, which refers only to the jury's determination.
Department for Work and …
London Ambulance Service NHS …
Metropolitan Police
Steven Rogers
All Responded
A doctor discharged a patient without seeing them, indicating a fundamental lack of understanding of discharge importance, and staff erroneously omitted long-acting insulin during the …
Stockport NHS Foundation Trust
Lee Rushton
Unknown
There is a lack of clear policy and training regarding how ACCT care plans and mandatory reviews should integrate with Cell Sharing Risk Assessments requiring …
Irene Pearson
Partially Responded
Matrifen patch warnings about hot baths are obscure and vague, and dangerous advice was given to use baths for patch removal. Poor liaison on opiate …
Takeda UK Ltd
Macmillan Cancer Support
Churchgate Surgery
Norah Fairhurst
All Responded
Older large goods vehicles, not mandated to have Class VI "cyclops" mirrors, have a dangerous blind spot directly in front, making pedestrians invisible to the …
Department for Transport
Jasmine Lapsley
All Responded
Emergency services in rural NW Wales suffer from a lack of nighttime air support, ineffective rostering and communication for Community First Responders, and inadequate resource …
Welsh Ambulance NHS Trust
Welsh Assembly Government
Lee Rigby
Historic (No Identified Response)
Systemic failures in care provision include support workers lacking keys, leaving residents unsupervised, and inadequate staffing levels, training, and procedural adherence regarding care plans and …
United Response
Arenijus Nedzelskies
Partially Responded
Specific synthetic cannabinoid receptor agonists (5F AKB-48, 5F PB-22) are not controlled substances, and the deceased's chronic misuse was not reported to the DVLA.
Home Office
Driver and Vehicle Licensing …
Anne Scott
Historic (No Identified Response)
Community care providers lacked training to correctly interpret and act upon data from health monitoring devices, and county-wide safeguarding recommendations for such training remain unconfirmed.
Cornwall and Isles of …
Colin Williams
Historic (No Identified Response)
A client with complex health and social needs, exacerbated by alcoholism, experienced "agency blindness" and lacked consistent support due to fragmented services, funding changes, and …
Cornwall Council Local Adult …
Emily Milligan
Historic (No Identified Response)
The increased speed and power of modern power boat leisure craft introduce additional risks, requiring greater awareness from users to prevent accidents.
British Maritime Federation
Royal Yachting Association
Robin Brett
Historic (No Identified Response)
A missed steroid dose went unnoticed due to a lack of system alerts on both paper and electronic drug charts for patients on long-term steroid …
Great Western Hospital NHS …
Nicholas Milligan
Historic (No Identified Response)
British Maritime Federation
Royal Yachting Association
Stefen Boswell
All Responded
Inconsistent police pursuit policies between local and national guidelines on wrong-way driving, coupled with inadequate communication systems for critical pursuit details, created unnecessary risks.
West Mercia Police
Norman Dorn
Historic (No Identified Response)
Cornwall care homes may lack adequate or updated policies for recognising and confirming death and for resuscitation, with staff often lacking awareness and proper training.
Care Quality Commission
Cornwall and Isles of …
Joanne French
Historic (No Identified Response)
Early patient discharge was hampered by unclear assessment requirements, a failure to include family input in decision-making, and inaccurate or incomplete discharge assessment notes.
Sussex Partnership NHS Trust
Thomas Burchell
Partially Responded
Inadequate and incomplete medical and nursing record-keeping, particularly a poorly maintained seizure chart, failed to accurately document a patient's critical seizure events.
Hospital NHS Trust Derriford …
Borchardt Medical Centre
Mark Holdsworth
Historic (No Identified Response)
Police failed to communicate critical information about the deceased's recent suicide threat to arresting officers and custody staff, resulting in an incomplete risk assessment upon …
Lincolnshire Police
Matthew Wood
Partially Responded
Department for Transport
London Heliport
Civil Aviation Authority
Peter Barnes
Partially Responded
Inadequate planning policies for tall buildings around the London Heliport fail to ensure safety, lacking in-depth consultation with the Heliport and official safeguarding measures, despite …
London Heliport
Civil Aviation Authority
Department for Transport
Gary Peel
Unknown
The need for deterrent measures on viaduct walls should be reviewed to prevent future deaths from individuals jumping.
Margaret Pegnall
Unknown
A GP practice had a vague domestic abuse flowchart focused on depression, lacked a specific domestic abuse questionnaire, and had no system for escalating urgent …
Mollie Bentham
Unknown
Repeated family concerns about abdominal pain and rising infection markers were not documented, escalated to medical teams, or examined, leading to a significant delay in …
Imran Douglas
All Responded
London Borough of Tower …
General Medical Council
National Offender Management Service
Angela Brealey
Partially Responded
The trust lacked clear procedures for handling third-party information, showed minimal multidisciplinary team involvement in patient care, and its serious incident review process failed to …
South Staffordshire and Shropshire …
St George’s Hospital
Christopher Higgins
All Responded
Inconsistent mental health observation practices, inadequate patient escort protocols during police transfers, unassessed safety risks in the environment, and poor inter-agency agreements for A&E assessment …
James Paget University Hospital
Norfolk and Norwich University …
Norfolk and Suffolk NHS …
Queen Elizabeth Hospital
Shalini Ganesh-Ram
Historic (No Identified Response)
Delayed diagnosis of a caecum perforation due to multiple systemic failures, including overlooked warning signs, delayed CT scans, inadequate interpretation of radiology findings, and improper …
Royal London Hospital
Kay Sheard
Unknown
Pulse oximeter alarm settings are fixed at a routine level rather than being adjusted to individual patient baselines, risking unnoticed significant oxygen desaturation.
Mary Hollands
Unknown
The system for providing radiologist reports to the Emergency Department is unreliable, creating a risk that subtle injuries may be missed and patient safety netting …
James Graham
Unknown
Critical communication failures between primary care and podiatry, coupled with a lack of ownership in referral processes and administrative errors, caused significant delays in secondary …
Edna Cleaton
Unknown
The practice lacked systems for regular medical reviews of patients on citalopram, resulting in a three-year delay in review and a missed opportunity to identify …
William Driscoll
Unknown
There are serious deficiencies in the medical assessment process for drivers, including insufficient investigation of health conditions, leading to inadequately assessed individuals being permitted to …
Ruth Smith
Unknown
There were significant delays in doctor review, inadequate nursing observations, and poor record-keeping by both nursing and medical staff. Crucial follow-up for medical interventions was …
Derek Thomas
All Responded
Prison reception procedures failed under extreme pressure, leading to suicide risk information being overlooked due to staffing issues. Additionally, there was poor communication and conflicting …
National Offender Management Service
HMP Durham
G4S
GEOAmey
Joyce Tozer
Unknown
Omnipaque is frequently administered at doses exceeding manufacturer's guidelines, sometimes via central lines, which exposes interventional radiology patients to potential toxicity risks.
Kamrul Rubel
Unknown
The gym did not enforce the use of the emergency stop cord despite providing advice, raising concerns about adherence to safety protocols for gym equipment.
William Maskell
Unknown
The absence of clear protocols and an overemphasis on student autonomy led to delayed intervention and reluctance to force entry for a student in distress, …
Paul Whitehead
Unknown
Emergency response procedures were inefficient, with delays in contacting emergency services, inadequate first aid provision, and difficulties for paramedics locating the casualty on-site.