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.
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a non-response confirmed by the Chief Coroner.
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6,254 reports
· Page 101 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 14 Dec 2015 |
Daniel Byrne
There were repeated failures to identify and assess suicide risk in newly arrived prisoners, with nursing staff notably …
|
Unknown | 0/0 | |
| 14 Dec 2015 |
Alan Walker
Critical information was not consistently recorded in nursing notes, and handovers did not reference these records, risking significant …
|
Unknown | 0/0 | |
| 14 Dec 2015 |
Kevin Gilbert
There was confusion and unreasonable delay in transferring an acute aortic dissection patient to a tertiary center, including …
|
Unknown | 0/0 | |
| 14 Dec 2015 |
Julie Rose
The "Unable to Make Contact Protocol" lacks clarity on mandatory police welfare checks for high-risk patients, and staff …
|
Unknown | 0/0 | |
| 11 Dec 2015 |
Margaret O’Brien
Staff lacked specific, prescribed training on how to properly conduct and record observations of residents.
|
Unknown | 0/0 | |
| 10 Dec 2015 |
Ololade Olaobaju
There is no joint guidance for "Can't Intubate Can't Oxygenate" situations when both anaesthetists and ENT surgeons are …
|
Unknown | 0/0 | |
| 9 Dec 2015 |
Jake Robinson
The provided concerns text is incomplete, preventing a proper summary of the identified safety issues.
|
Bodmin Road Health Centre Greater Manchester NHS Area Team Greater Manchester West Health NHS … | All Responded | 3/3 |
| 8 Dec 2015 |
Madhumita Mandal
An emergency department streaming model that relied on untrained receptionists without medical observations led to critical delays in …
|
Unknown | 0/0 | |
| 4 Dec 2015 |
Elsie Brown
Absent falls/bed rails assessments, incomplete care plans, poor record-keeping, inadequate night staffing, and informal handovers created significant safety …
|
Unknown | 0/0 | |
| 3 Dec 2015 |
Codrut Iederan
The construction site had inadequate first aid provision, with the designated first aider off-site and non-English speaking workers …
|
Unknown | 0/0 | |
| 1 Dec 2015 |
Bryan Catanach
Significant communication failures between clinicians and staff led to delays in patient transfer, senior review, and confusion over …
|
Unknown | 0/0 | |
| 1 Dec 2015 |
Barbara Rawlinson
Pre-hysterectomy CT scans are not routinely performed, relying solely on ultrasound. This raises concern that uterine sarcoma diagnoses …
|
Royal Free London NHS Foundation … | Historic (No Identified Response) | 0/1 |
| 1 Dec 2015 |
Ricky Hudson
Quad bike riders on public roads are not required to wear crash helmets or possess additional driving qualifications, …
|
Unknown | 0/0 | |
| 30 Nov 2015 |
Stephen Adams
Mental Health Liaison Team risk assessment forms are inadequately completed, with the suicide risk box frequently left blank. …
|
Unknown | 0/0 | |
| 27 Nov 2015 |
Thelma Clarkson
The NICE Head Injury Pathway fails to include Clopidogrel as a trigger for CT scans, unlike Warfarin, despite …
|
Unknown | 0/0 | |
| 27 Nov 2015 |
Darren Jones
Inadequate protocols exist for seeking renal advice for transplant patients, especially concerning immunosuppressant medication interactions. Additionally, there are …
|
Unknown | 0/0 | |
| 26 Nov 2015 |
Robert Mansfield
Three deaths at the Millpond indicate significant safety concerns, highlighting the need for fencing, improved lighting, clear warning …
|
Unknown | 0/0 | |
| 25 Nov 2015 |
Dean Boland
Pervasive drug issues in the prison are exacerbated by a lack of officer awareness, poor multi-disciplinary communication, and …
|
Birmingham Community Healthcare NHS Trust Birmingham Prison National Offender Management Service | Partially Responded | 1/3 |
| 25 Nov 2015 |
Thomas Collins
The attending paramedic lacked confidence in making a clinical decision and inappropriately deferred to an out-of-hours service, indicating …
|
Haughton Thornley Medical Centres North West Ambulance Service | All Responded | 2/2 |
| 24 Nov 2015 |
Piotr Kucharz
Mental health staff displayed a critical lack of consistency and clarity on what constitutes an effective patient observation, …
|
Lancashire Care NHS Foundation Trust | All Responded | 1/1 |
| 24 Nov 2015 |
Thomas Black
Prison staff failed to seek timely medical advice for a clearly unwell prisoner, indicating a critical lapse in …
|
HMP Usk | Historic (No Identified Response) | 0/1 |
| 24 Nov 2015 |
Jonathan Hawes
The 60 mph speed limit on Cowleaze Hill is unsafe due to blind bends and cambers. There is …
|
Islands Roads | All Responded | 1/1 |
| 23 Nov 2015 |
Alan Ludlow
Critical information about residents' past incidents and risks is not adequately exchanged between care providers during placement. This …
|
Kent County Council | Historic (No Identified Response) | 0/1 |
| 17 Nov 2015 |
Frank Mellers
There was a critical failure to communicate DNAR status with the family and between medical/nursing staff, leading to …
|
Walsall Manor Hospital | All Responded | 1/1 |
| 16 Nov 2015 |
Nadine Brookes-Walker
Packaging for Fentanyl patches may not adequately convey the severe risks associated with using damaged patches, potentially leading …
|
Teva UK Ltd | All Responded | 1/1 |
| 16 Nov 2015 |
Emma Bray
Systemic failures in mental health services include inadequate patient assessment, missed referrals, and absent follow-up. Critical family information …
|
Policy and Patient Safety Directorate | All Responded | 1/1 |
| 16 Nov 2015 |
Christine McNamara
There is a lack of clear pathways for post-ERCP patients with complications, and out-of-hours radiography is hampered by …
|
Maidstone and Tunbridge Wells NHS … | All Responded | 1/1 |
| 13 Nov 2015 |
Irene Scholey
No specific concerns were detailed in the provided text, which instead referred to an external narrative conclusion.
|
Wakefield District Safeguarding Adults Board | Historic (No Identified Response) | 0/1 |
| 12 Nov 2015 |
Guy Robinson
The 'AWOL' protocol was improperly applied due to staff unfamiliarity, lacking Trust-wide implementation. A significant service gap exists …
|
Pennine Care NHS Trust | All Responded | 1/1 |
| 12 Nov 2015 |
Christopher Connor
Ambulance response was delayed, only arriving after police expedited the call, indicating potential issues with emergency service dispatch …
|
Welsh Ambulance Trust | All Responded | 1/1 |
| 12 Nov 2015 |
Matthew Groom
Significant delays occurred in mental health assessment and prescribed medication administration. Staff failed to plan for patient elopement, …
|
Camden & Islington NHS Trust Whittington Hospital NHS Trust | All Responded | 2/2 |
| 11 Nov 2015 |
Alexander Hadley
The absence of warning signs at a public waterfall meant people were unaware of dangerous currents, creating a …
|
Gwynedd Council | All Responded | 1/1 |
| 11 Nov 2015 |
David White
Critical medication side effects causing confusion were unrecorded and unaddressed. Despite documented fall risks in nursing notes, adequate …
|
Barts Health NHS Trust | All Responded | 1/1 |
| 9 Nov 2015 |
John Moreton
A pedestrian stile leads directly onto a busy dual carriageway with a national speed limit, and there are …
|
Highways Agency | Historic (No Identified Response) | 0/1 |
| 6 Nov 2015 |
Brian Shillinglaw
The provided text is incomplete and does not contain specific concerns.
|
Sussex Partnership Trust | Historic (No Identified Response) | 0/1 |
| 6 Nov 2015 |
Carl Hughes
Motorcross events do not mandate body protection for competitors, which could prevent fatal injuries.
|
Motor Cross Federation | All Responded | 1/1 |
| 6 Nov 2015 |
Vera Williams
Emergency Department doctors and staff lack a digital system to support their work.
|
Betsi Cadwaladr University NHS Trust | Historic (No Identified Response) | 0/1 |
| 4 Nov 2015 |
Michael Logue
A general practitioner failed to conduct a physical examination during a home visit for a post-surgery patient complaining …
|
Central Surgery | All Responded | 1/1 |
| 3 Nov 2015 |
Peter Buckle
An unsafe work method was adopted without a risk assessment, and a strong health and safety culture was …
|
Wayland Farms Limited | All Responded | 1/1 |
| 3 Nov 2015 |
David Pooley
A named nurse was not allocated until the day before death, breaching trust policy and resulting in a …
|
South Essex Mental Health Partnership … | Historic (No Identified Response) | 0/1 |
| 2 Nov 2015 |
Steven Jackson
A paramedic failed to effectively use the sepsis screening tool, indicating a need for better training for ambulance …
|
East of England Ambulance Service … General Medical Council | Historic (No Identified Response) | 0/2 |
| 2 Nov 2015 |
Marie Quinn
Sub-optimal DVT prophylaxis, including delayed medication and missing mechanical treatment, was provided. Incorrect discharge instructions led to early …
|
HC-One Limited | Historic (No Identified Response) | 0/1 |
| 2 Nov 2015 |
Jacqueline Williams
The mental health referral system was prone to human error, failing to provide ED staff with confirmation of …
|
East Lancashire NHS Trust | All Responded | 1/1 |
| 2 Nov 2015 |
Jean Gillespie
Senior care staff lacked awareness of a resident's life-threatening condition and medication, failing to appreciate the urgency of …
|
Alexandra Court Care Home | All Responded | 1/1 |
| 2 Nov 2015 |
Richard Green
Prison medical professionals failed to act on recorded self-harm history in SystmOne due to system usability issues, workload …
|
National Offender Management Service Ministry of Justice | Partially Responded | 1/2 |
| 2 Nov 2015 |
Connor Sparrowhawk
The bath time observation policy for epileptic patients is inadequate, with concerns about the effectiveness of sound-only monitoring …
|
Southern Health NHS Foundation Trust | All Responded | 1/1 |
| 30 Oct 2015 |
Mary Bloom
Trust policy on heparin administration was not followed, including failure to weigh the patient, consult haematology, or take …
|
Barking, Havering and Redbridge University … | All Responded | 1/1 |
| 30 Oct 2015 |
Dennis Stark
A rehabilitation unit's lack of a lift significantly delayed the emergency removal of an obese patient from a …
|
Newton House (formerly Regency Hospital) | Historic (No Identified Response) | 0/1 |
| 29 Oct 2015 |
Florence Lowe
A 60mph speed limit on a road with residential properties and busy amenities is inappropriate, and a major …
|
Staffordshire County Council | Historic (No Identified Response) | 0/1 |
| 29 Oct 2015 |
Hilda Haughton
Patient falls resulted from unraised cot sides and were compounded by a lack of hospital staff candour. Concerns …
|
Tameside Hospital NHS Foundation Trust | All Responded | 2/1 |
Daniel Byrne
Unknown
There were repeated failures to identify and assess suicide risk in newly arrived prisoners, with nursing staff notably absent from initial health screenings and reviews.
Alan Walker
Unknown
Critical information was not consistently recorded in nursing notes, and handovers did not reference these records, risking significant patient details being missed by incoming staff.
Kevin Gilbert
Unknown
There was confusion and unreasonable delay in transferring an acute aortic dissection patient to a tertiary center, including a failure to escalate the transfer decision …
Julie Rose
Unknown
The "Unable to Make Contact Protocol" lacks clarity on mandatory police welfare checks for high-risk patients, and staff demonstrated inadequate understanding of its procedures.
Margaret O’Brien
Unknown
Staff lacked specific, prescribed training on how to properly conduct and record observations of residents.
Ololade Olaobaju
Unknown
There is no joint guidance for "Can't Intubate Can't Oxygenate" situations when both anaesthetists and ENT surgeons are present, leading to inconsistent clinical judgments and …
Jake Robinson
All Responded
The provided concerns text is incomplete, preventing a proper summary of the identified safety issues.
Bodmin Road Health Centre
Greater Manchester NHS Area …
Greater Manchester West Health …
Madhumita Mandal
Unknown
An emergency department streaming model that relied on untrained receptionists without medical observations led to critical delays in patient assessment by qualified healthcare professionals.
Elsie Brown
Unknown
Absent falls/bed rails assessments, incomplete care plans, poor record-keeping, inadequate night staffing, and informal handovers created significant safety risks due to unclear staff responsibilities.
Codrut Iederan
Unknown
The construction site had inadequate first aid provision, with the designated first aider off-site and non-English speaking workers untrained and unaware of how to summon …
Bryan Catanach
Unknown
Significant communication failures between clinicians and staff led to delays in patient transfer, senior review, and confusion over care instructions. Additionally, inadequate patient supervision resulted …
Barbara Rawlinson
Historic (No Identified Response)
Pre-hysterectomy CT scans are not routinely performed, relying solely on ultrasound. This raises concern that uterine sarcoma diagnoses could be missed due to inadequate diagnostic …
Royal Free London NHS …
Ricky Hudson
Unknown
Quad bike riders on public roads are not required to wear crash helmets or possess additional driving qualifications, posing significant safety risks due to insufficient …
Stephen Adams
Unknown
Mental Health Liaison Team risk assessment forms are inadequately completed, with the suicide risk box frequently left blank. This leads to crucial risk information not …
Thelma Clarkson
Unknown
The NICE Head Injury Pathway fails to include Clopidogrel as a trigger for CT scans, unlike Warfarin, despite its known bleeding risk. This omission can …
Darren Jones
Unknown
Inadequate protocols exist for seeking renal advice for transplant patients, especially concerning immunosuppressant medication interactions. Additionally, there are delays in obtaining essential immunosuppressant drugs at …
Robert Mansfield
Unknown
Three deaths at the Millpond indicate significant safety concerns, highlighting the need for fencing, improved lighting, clear warning notices, and readily available flotation equipment.
Dean Boland
Partially Responded
Pervasive drug issues in the prison are exacerbated by a lack of officer awareness, poor multi-disciplinary communication, and insufficient drug administration checks. Inadequate cell searches, …
Birmingham Community Healthcare NHS …
Birmingham Prison
National Offender Management Service
Thomas Collins
All Responded
The attending paramedic lacked confidence in making a clinical decision and inappropriately deferred to an out-of-hours service, indicating a potential training or support gap.
Haughton Thornley Medical Centres
North West Ambulance Service
Piotr Kucharz
All Responded
Mental health staff displayed a critical lack of consistency and clarity on what constitutes an effective patient observation, with some failing to enter rooms or …
Lancashire Care NHS Foundation …
Thomas Black
Historic (No Identified Response)
Prison staff failed to seek timely medical advice for a clearly unwell prisoner, indicating a critical lapse in duty of care and health monitoring.
HMP Usk
Jonathan Hawes
All Responded
The 60 mph speed limit on Cowleaze Hill is unsafe due to blind bends and cambers. There is a critical need to reconsider the speed …
Islands Roads
Alan Ludlow
Historic (No Identified Response)
Critical information about residents' past incidents and risks is not adequately exchanged between care providers during placement. This leads to new homes being unaware of …
Kent County Council
Frank Mellers
All Responded
There was a critical failure to communicate DNAR status with the family and between medical/nursing staff, leading to attempted resuscitation despite a DNAR order. Policies …
Walsall Manor Hospital
Nadine Brookes-Walker
All Responded
Packaging for Fentanyl patches may not adequately convey the severe risks associated with using damaged patches, potentially leading to patient misuse.
Teva UK Ltd
Emma Bray
All Responded
Systemic failures in mental health services include inadequate patient assessment, missed referrals, and absent follow-up. Critical family information about deterioration was ignored, leading to delayed …
Policy and Patient Safety …
Christine McNamara
All Responded
There is a lack of clear pathways for post-ERCP patients with complications, and out-of-hours radiography is hampered by the absence of a Maidstone surgical consultant …
Maidstone and Tunbridge Wells …
Irene Scholey
Historic (No Identified Response)
No specific concerns were detailed in the provided text, which instead referred to an external narrative conclusion.
Wakefield District Safeguarding Adults …
Guy Robinson
All Responded
The 'AWOL' protocol was improperly applied due to staff unfamiliarity, lacking Trust-wide implementation. A significant service gap exists with no inpatient clinical psychology access, disadvantaging …
Pennine Care NHS Trust
Christopher Connor
All Responded
Ambulance response was delayed, only arriving after police expedited the call, indicating potential issues with emergency service dispatch or prioritization.
Welsh Ambulance Trust
Matthew Groom
All Responded
Significant delays occurred in mental health assessment and prescribed medication administration. Staff failed to plan for patient elopement, did not involve hospital security, and inadequately …
Camden & Islington NHS …
Whittington Hospital NHS Trust
Alexander Hadley
All Responded
The absence of warning signs at a public waterfall meant people were unaware of dangerous currents, creating a risk of further accidental deaths.
Gwynedd Council
David White
All Responded
Critical medication side effects causing confusion were unrecorded and unaddressed. Despite documented fall risks in nursing notes, adequate supervision was absent, and these notes were …
Barts Health NHS Trust
John Moreton
Historic (No Identified Response)
A pedestrian stile leads directly onto a busy dual carriageway with a national speed limit, and there are no warning signs for pedestrians or motorists …
Highways Agency
Brian Shillinglaw
Historic (No Identified Response)
The provided text is incomplete and does not contain specific concerns.
Sussex Partnership Trust
Carl Hughes
All Responded
Motorcross events do not mandate body protection for competitors, which could prevent fatal injuries.
Motor Cross Federation
Vera Williams
Historic (No Identified Response)
Emergency Department doctors and staff lack a digital system to support their work.
Betsi Cadwaladr University NHS …
Michael Logue
All Responded
A general practitioner failed to conduct a physical examination during a home visit for a post-surgery patient complaining of pain and ill health.
Central Surgery
Peter Buckle
All Responded
An unsafe work method was adopted without a risk assessment, and a strong health and safety culture was absent among employees despite training.
Wayland Farms Limited
David Pooley
Historic (No Identified Response)
A named nurse was not allocated until the day before death, breaching trust policy and resulting in a failure to carry out essential risk assessments …
South Essex Mental Health …
Steven Jackson
Historic (No Identified Response)
A paramedic failed to effectively use the sepsis screening tool, indicating a need for better training for ambulance staff on its use and appropriate patient …
East of England Ambulance …
General Medical Council
Marie Quinn
Historic (No Identified Response)
Sub-optimal DVT prophylaxis, including delayed medication and missing mechanical treatment, was provided. Incorrect discharge instructions led to early cessation, and the nursing home failed to …
HC-One Limited
Jacqueline Williams
All Responded
The mental health referral system was prone to human error, failing to provide ED staff with confirmation of accepted referrals or assessment times. The Mental …
East Lancashire NHS Trust
Jean Gillespie
All Responded
Senior care staff lacked awareness of a resident's life-threatening condition and medication, failing to appreciate the urgency of re-ordering supplies. Care home records also lacked …
Alexandra Court Care Home
Richard Green
Partially Responded
Prison medical professionals failed to act on recorded self-harm history in SystmOne due to system usability issues, workload pressure, and a lack of clear display …
National Offender Management Service
Ministry of Justice
Connor Sparrowhawk
All Responded
The bath time observation policy for epileptic patients is inadequate, with concerns about the effectiveness of sound-only monitoring and potential staff distraction. The RIO system …
Southern Health NHS Foundation …
Mary Bloom
All Responded
Trust policy on heparin administration was not followed, including failure to weigh the patient, consult haematology, or take post-hydration bloods. Critical dosage advice for underweight …
Barking, Havering and Redbridge …
Dennis Stark
Historic (No Identified Response)
A rehabilitation unit's lack of a lift significantly delayed the emergency removal of an obese patient from a second-floor room, posing a risk of future …
Newton House (formerly Regency …
Florence Lowe
Historic (No Identified Response)
A 60mph speed limit on a road with residential properties and busy amenities is inappropriate, and a major roundabout lacks a pedestrian crossing. Other local …
Staffordshire County Council
Hilda Haughton
All Responded
Patient falls resulted from unraised cot sides and were compounded by a lack of hospital staff candour. Concerns were also raised regarding the safety of …
Tameside Hospital NHS Foundation …