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 102 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 |
| 28 Oct 2015 |
Kevin Forster
HMP Durham had a serious drug problem, but staff lacked awareness and training on overdose policies, leading to …
|
G4S National Offender Management Service | All Responded | 2/2 |
| 28 Oct 2015 |
Christopher Smith
A 12-minute ambulance call delay resulted from communication breakdown between police control rooms regarding responsibility. A clear procedure …
|
Greater Manchester Police | Historic (No Identified Response) | 0/1 |
| 27 Oct 2015 |
Bartosz Bortniczak
The 40mph speed restriction is placed after a dangerous road bend, rather than before it, despite multiple incidents, …
|
Doncaster Highways Services | All Responded | 1/1 |
| 27 Oct 2015 |
Charlotte Bevan and Zaani Malbrouck
There was no mandatory multi-disciplinary team meeting or widely circulated care plan for pregnant women with known mental …
|
Avon and Wiltshire Mental Health … | All Responded | 1/1 |
| 27 Oct 2015 |
Scarlett Jukes
Neither public participants nor paid hunt staff are required to wear protective headgear that complies with recognised safety …
|
Health and Safety Executive Foxhound Association | Partially Responded | 1/2 |
| 27 Oct 2015 |
George Hines
Defects in the pull-cord alarm system were unaddressed, residents were responsible for smoke detector maintenance, and smoke detectors …
|
Bristol City Council | Historic (No Identified Response) | 0/1 |
| 26 Oct 2015 |
Carl Foot
Delayed prison cell bell responses, lack of a system to track bell activation times, and inadequate post-incident review …
|
HMP Pentonville | Historic (No Identified Response) | 0/1 |
| 26 Oct 2015 |
Allan Beasley
Care home staff were unaware of the falls prevention policy, leading to inaccurate recording, delayed escalation of falls, …
|
Unknown | 0/0 | |
| 26 Oct 2015 |
Neil Garry
A busy road frequently used by pedestrians, including children, lacks a pedestrian crossing, posing a significant safety risk.
|
Highways England | Historic (No Identified Response) | 0/1 |
| 26 Oct 2015 |
Wayne O’Neill
There was inadequate recognition of drug contraindications and dangerous psychotropic medication combinations, with no routine ECG monitoring performed …
|
Worcestershire Health and Care NHS … | All Responded | 1/1 |
| 26 Oct 2015 |
Barry Thraves
Significant delays in psychiatric follow-up, lack of community support, and poor communication between mental health teams and GPs …
|
Leicester City Council | All Responded | 2/1 |
| 23 Oct 2015 |
Samuel Gale
A prisoner's ACCT plan was closed without consulting crucial healthcare and management staff, suggesting a critical lapse in …
|
HMP and YOI Doncaster | All Responded | 2/1 |
| 23 Oct 2015 |
Margaret Ferry
The absence of a formal policy and poor communication between two NHS Trusts resulted in unclear responsibilities and …
|
City Hospitals Sunderland NHS Foundation … | All Responded | 1/1 |
| 23 Oct 2015 |
Hireiti Kuflesion
Pregnant women with mechanical heart valves received insufficient Clexane dosing and monitoring, combined with clinicians' lack of understanding …
|
Birmingham Women’s NHS Trust N.I.C.E University Hospitals Birmingham NHS Trust | Historic (No Identified Response) | 0/3 |
| 22 Oct 2015 |
Richard Laco
Critical construction method variations were undocumented in safety plans, and key personnel lacked understanding of procedures, leading to …
|
CMF Limited Laing O’Rourke UK & Europe | All Responded | 2/2 |
| 22 Oct 2015 |
Harry Mellor
There is no reliable system to track child GP de-registration, creating significant safeguarding risks, especially for children with …
|
Department of Health and Social … General Medical Council Nottingham City Clinical Commissioning Group Nottinghamshire Safeguarding Children Board Public Health England | Partially Responded | 4/5 |
| 22 Oct 2015 |
Glenda Day
A doctor granted home leave without reviewing the patient or updating risk assessments, exposing a lack of clear …
|
Nottinghamshire Healthcare NHS Trust | Historic (No Identified Response) | 0/1 |
| 22 Oct 2015 |
Diane Knight
The practice of placing towels over doors on the unit obstructed staff monitoring and could conceal self-harm attempts, …
|
Devon Partnership Trust | All Responded | 1/1 |
| 21 Oct 2015 |
David Baddeley
Incompatible electronic records, poor communication between practices, and delayed record reviews led to critical mental health diagnoses and …
|
Greater Manchester NHS Area Team | All Responded | 1/1 |
| 21 Oct 2015 |
Samantha Beach
There were critical failures in escalating clinical care and a profound lack of information sharing and coordinated care …
|
Gloucestershire Hospitals NHS Trust | Historic (No Identified Response) | 0/1 |
| 21 Oct 2015 |
Dorothy Cooper
Inadequate information transfer during inter-hospital referrals and the receiving team's failure to proactively address missing clinical data risked …
|
Leeds Teaching Hospitals NHS Trust Mid Yorkshire NHS Trust | All Responded | 2/2 |
| 20 Oct 2015 |
William Abel
Failure to conduct a Mental Health Act assessment and inadequate communication with family regarding the patient's suicidal intentions …
|
Leicester Partnership NHS Trust | All Responded | 1/1 |
| 20 Oct 2015 |
Erich Speilmann
The quality of street lighting at the incident location was poor and may have contributed to the event.
|
Essex Highways Agency | Historic (No Identified Response) | 0/1 |
| 19 Oct 2015 |
Kyle Hull
Inadequate CCTV coverage and monitoring may fail to detect risks of self-harm, property damage, or identify dangerous areas …
|
Darlington Cattle Mart | All Responded | 1/1 |
| 19 Oct 2015 |
Vasilis Ktorakis
Clinical errors included delayed medication and poor judgment during labor. Systemic failures in incident investigation, note-taking, and providing …
|
Whittington Hospital NHS Trust | All Responded | 1/1 |
| 16 Oct 2015 |
Caroline Robey
Community healthcare providers failed to use a sepsis screening tool or adopt the national sepsis clinical toolkit, leading …
|
East Midlands Ambulance Service NHS England | All Responded | 2/2 |
| 16 Oct 2015 |
Adrian Smith
A clear instruction for an MRI scan from a specialist hospital was not followed by staff at another …
|
Heart of England NHS Foundation … NHS England | Partially Responded | 1/2 |
| 15 Oct 2015 |
William Tolen
Significant failures in care home note-keeping, staff training, and communication led to delayed essential care. Procedures were performed …
|
Shawe Lodge | All Responded | 1/1 |
| 14 Oct 2015 |
Alan Tear
Post-operative instructions were not followed, and rising EWS observations were not reported to medical staff. Communication between interventional …
|
University Hospitals of Leicester NHS … | All Responded | 1/1 |
| 13 Oct 2015 |
Nathaniel Phillips
Brittle asthma, a life-threatening condition, is not covered by medical exemption certificates, causing patients to miss medication due …
|
Department of Health and Social … | All Responded | 1/1 |
| 13 Oct 2015 |
Catherine Findlay
Concerns about the availability and misuse of dangerous "research chemicals" like MXP, which are freely marketed online, consumed, …
|
Advisory Council on the Misuse … Home Office Minister of State for Crime … | Partially Responded | 1/3 |
| 12 Oct 2015 |
Mrs Withers
Systemic policy deficiencies in emergency services included failing to obtain patient medical history during 999 calls, inadequate call-back …
|
Kettering General Hospital NHS Trust | Historic (No Identified Response) | 0/1 |
| 9 Oct 2015 |
Patrick Carrick
There was an unexplained departure from the patient's management plan during rapid deterioration, crucial blood results were not …
|
North Tyneside General Hospital | All Responded | 1/1 |
| 9 Oct 2015 |
Suzanne Greenwood
Lack of systems and protocols for contacting patients who miss appointments, informing GPs of non-attendance or discharge, and …
|
Priory Hospital | All Responded | 1/1 |
| 8 Oct 2015 |
Solomon Bealey
Despite initial concerns about a patient's suicidal ideation and a history of self-harm, no effective follow-up action was …
|
Norwich Practices Health Centre | All Responded | 1/1 |
| 8 Oct 2015 |
Maureen Chatterley
Lack of investigation into alleged medication overdose and inadequate stock control for non-controlled drugs on wards, preventing verification …
|
Royal Bolton Hospital | All Responded | 1/1 |
| 8 Oct 2015 |
Rebecca Jones
Concerns involved the failure to conduct a Section 136 mental health assessment within the expected three-hour timeframe, and …
|
Department of Health and Social … | All Responded | 1/1 |
| 7 Oct 2015 |
Dilys Jenkins
Tracheostomy tube manufacturers may not be keeping pace with population changes, leading to tubes of potentially inappropriate length …
|
Intensive Care Society of England … | Historic (No Identified Response) | 0/1 |
| 7 Oct 2015 |
Naiya Diarra
Relevant patient information was inaccessible to clinicians due to being stored in disparate record systems, highlighting systemic failures …
|
National Institute for Health Care … | Historic (No Identified Response) | 0/1 |
| 7 Oct 2015 |
Geoffrey Parry
Critical ECG test results were unavailable pre-surgery due to systemic record management issues. An unlabelled intravenous line was …
|
Cardiff and Vale University Health … | All Responded | 1/1 |
| 7 Oct 2015 |
Edward Gascoigne
Relevant patient information was inaccessible to clinicians due to being stored in disparate record systems, highlighting systemic failures …
|
Department of Health and Social … | All Responded | 1/1 |
| 5 Oct 2015 |
Peter Furness
The care home lacked a documented process for escalating incidents and concerns to trigger multi-disciplinary team meetings for …
|
Nant y Gaer Hall Nursing … | All Responded | 1/1 |
| 2 Oct 2015 |
Rosina Drury
The absence of a pre-operative orthogeriatric review for patients with femoral neck fractures risks inappropriate cemented hemiarthroplasty, potentially …
|
Kings College Hospital | Historic (No Identified Response) | 0/1 |
| 1 Oct 2015 |
Charles Rayner
The highway crossover point lacks a deceleration lane and clear signage, forcing westbound traffic to slow dangerously in …
|
Highways England | Historic (No Identified Response) | 0/1 |
| 1 Oct 2015 |
John Lomas
Inadequate risk assessment of river conditions, lack of essential safety protocols for white water rafting (e.g., training, safety …
|
Sports Camp Tirol | All Responded | 1/1 |
| 1 Oct 2015 |
Kenneth McCurdy and Mary McCurdy
The absence of clear signage at a central reservation gap fails to indicate prohibited right turns or U-turns …
|
Highways England | All Responded | 1/1 |
| 30 Sep 2015 |
Jean Hannon
A critical diagnosis (autonomic dysreflexia) was not sufficiently highlighted in medical records, leading to a consultant's unawareness during …
|
East Lancashire Healthcare NHS Trust | All Responded | 1/1 |
| 29 Sep 2015 |
Parv Patel
The current PEWS scores are not aligned with research on child illness and may dangerously distract doctors from …
|
Department of Health and Social … | All Responded | 1/1 |
| 29 Sep 2015 |
Ethan Johnson
There was a critical lack of leadership and support for junior staff managing an abnormal CTG trace, compounded …
|
Milton Keynes Hospital | All Responded | 1/1 |
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
Kevin Forster
All Responded
HMP Durham had a serious drug problem, but staff lacked awareness and training on overdose policies, leading to complacent responses, inadequate treatment plans, and delayed …
G4S
National Offender Management Service
Christopher Smith
Historic (No Identified Response)
A 12-minute ambulance call delay resulted from communication breakdown between police control rooms regarding responsibility. A clear procedure is required to prevent future delays, especially …
Greater Manchester Police
Bartosz Bortniczak
All Responded
The 40mph speed restriction is placed after a dangerous road bend, rather than before it, despite multiple incidents, unnecessarily increasing the risk of collisions.
Doncaster Highways Services
Charlotte Bevan and Zaani Malbrouck
All Responded
There was no mandatory multi-disciplinary team meeting or widely circulated care plan for pregnant women with known mental health conditions, risking fragmented and uncoordinated care.
Avon and Wiltshire Mental …
Scarlett Jukes
Partially Responded
Neither public participants nor paid hunt staff are required to wear protective headgear that complies with recognised safety standards during hunting events, posing a significant …
Health and Safety Executive
Foxhound Association
George Hines
Historic (No Identified Response)
Defects in the pull-cord alarm system were unaddressed, residents were responsible for smoke detector maintenance, and smoke detectors were not linked to the emergency control …
Bristol City Council
Carl Foot
Historic (No Identified Response)
Delayed prison cell bell responses, lack of a system to track bell activation times, and inadequate post-incident review contributed to a prisoner's death.
HMP Pentonville
Allan Beasley
Unknown
Care home staff were unaware of the falls prevention policy, leading to inaccurate recording, delayed escalation of falls, and unreliable patient observation practices.
Neil Garry
Historic (No Identified Response)
A busy road frequently used by pedestrians, including children, lacks a pedestrian crossing, posing a significant safety risk.
Highways England
Wayne O’Neill
All Responded
There was inadequate recognition of drug contraindications and dangerous psychotropic medication combinations, with no routine ECG monitoring performed despite expert recommendations, leading to significant risks.
Worcestershire Health and Care …
Barry Thraves
All Responded
Significant delays in psychiatric follow-up, lack of community support, and poor communication between mental health teams and GPs led to unaddressed patient deterioration.
Leicester City Council
Samuel Gale
All Responded
A prisoner's ACCT plan was closed without consulting crucial healthcare and management staff, suggesting a critical lapse in multi-disciplinary oversight for vulnerable individuals.
HMP and YOI Doncaster
Margaret Ferry
All Responded
The absence of a formal policy and poor communication between two NHS Trusts resulted in unclear responsibilities and misunderstandings during patient referrals.
City Hospitals Sunderland NHS …
Hireiti Kuflesion
Historic (No Identified Response)
Pregnant women with mechanical heart valves received insufficient Clexane dosing and monitoring, combined with clinicians' lack of understanding of thrombosis risks, resulting in delayed diagnosis.
Birmingham Women’s NHS Trust
N.I.C.E
University Hospitals Birmingham NHS …
Richard Laco
All Responded
Critical construction method variations were undocumented in safety plans, and key personnel lacked understanding of procedures, leading to significant workplace safety risks.
CMF Limited
Laing O’Rourke UK & …
Harry Mellor
Partially Responded
There is no reliable system to track child GP de-registration, creating significant safeguarding risks, especially for children with chronic health needs, as specialist teams are …
Department of Health and …
General Medical Council
Nottingham City Clinical Commissioning …
Nottinghamshire Safeguarding Children Board
Public Health England
Glenda Day
Historic (No Identified Response)
A doctor granted home leave without reviewing the patient or updating risk assessments, exposing a lack of clear written policies and consistent, trust-wide adherence to …
Nottinghamshire Healthcare NHS Trust
Diane Knight
All Responded
The practice of placing towels over doors on the unit obstructed staff monitoring and could conceal self-harm attempts, requiring alternative patient privacy methods.
Devon Partnership Trust
David Baddeley
All Responded
Incompatible electronic records, poor communication between practices, and delayed record reviews led to critical mental health diagnoses and medication needs being repeatedly missed.
Greater Manchester NHS Area …
Samantha Beach
Historic (No Identified Response)
There were critical failures in escalating clinical care and a profound lack of information sharing and coordinated care among multiple departments and community services for …
Gloucestershire Hospitals NHS Trust
Dorothy Cooper
All Responded
Inadequate information transfer during inter-hospital referrals and the receiving team's failure to proactively address missing clinical data risked incorrect diagnoses and treatment plans.
Leeds Teaching Hospitals NHS …
Mid Yorkshire NHS Trust
William Abel
All Responded
Failure to conduct a Mental Health Act assessment and inadequate communication with family regarding the patient's suicidal intentions and mental health relapse led to unsafe …
Leicester Partnership NHS Trust
Erich Speilmann
Historic (No Identified Response)
The quality of street lighting at the incident location was poor and may have contributed to the event.
Essex Highways Agency
Kyle Hull
All Responded
Inadequate CCTV coverage and monitoring may fail to detect risks of self-harm, property damage, or identify dangerous areas like fragile roofs, hindering early intervention.
Darlington Cattle Mart
Vasilis Ktorakis
All Responded
Clinical errors included delayed medication and poor judgment during labor. Systemic failures in incident investigation, note-taking, and providing feedback prevented staff learning and improvement.
Whittington Hospital NHS Trust
Caroline Robey
All Responded
Community healthcare providers failed to use a sepsis screening tool or adopt the national sepsis clinical toolkit, leading to missed diagnosis opportunities and delayed emergency …
East Midlands Ambulance Service
NHS England
Adrian Smith
Partially Responded
A clear instruction for an MRI scan from a specialist hospital was not followed by staff at another hospital, highlighting a lack of systems to …
Heart of England NHS …
NHS England
William Tolen
All Responded
Significant failures in care home note-keeping, staff training, and communication led to delayed essential care. Procedures were performed unsafely and without adequate supervision or infection …
Shawe Lodge
Alan Tear
All Responded
Post-operative instructions were not followed, and rising EWS observations were not reported to medical staff. Communication between interventional radiology and nursing teams regarding observations was …
University Hospitals of Leicester …
Nathaniel Phillips
All Responded
Brittle asthma, a life-threatening condition, is not covered by medical exemption certificates, causing patients to miss medication due to cost and preventing GPs from escalating …
Department of Health and …
Catherine Findlay
Partially Responded
Concerns about the availability and misuse of dangerous "research chemicals" like MXP, which are freely marketed online, consumed, and pose a life-threatening risk.
Advisory Council on the …
Home Office
Minister of State for …
Mrs Withers
Historic (No Identified Response)
Systemic policy deficiencies in emergency services included failing to obtain patient medical history during 999 calls, inadequate call-back procedures, poor data saving, and inefficient handover …
Kettering General Hospital NHS …
Patrick Carrick
All Responded
There was an unexplained departure from the patient's management plan during rapid deterioration, crucial blood results were not actioned, and nursing/medical notes were inadequately completed.
North Tyneside General Hospital
Suzanne Greenwood
All Responded
Lack of systems and protocols for contacting patients who miss appointments, informing GPs of non-attendance or discharge, and ensuring continuity of care when patients are …
Priory Hospital
Solomon Bealey
All Responded
Despite initial concerns about a patient's suicidal ideation and a history of self-harm, no effective follow-up action was taken after failed contact attempts.
Norwich Practices Health Centre
Maureen Chatterley
All Responded
Lack of investigation into alleged medication overdose and inadequate stock control for non-controlled drugs on wards, preventing verification of medication quantities and increasing risk of …
Royal Bolton Hospital
Rebecca Jones
All Responded
Concerns involved the failure to conduct a Section 136 mental health assessment within the expected three-hour timeframe, and the need for facilities to ensure safe …
Department of Health and …
Dilys Jenkins
Historic (No Identified Response)
Tracheostomy tube manufacturers may not be keeping pace with population changes, leading to tubes of potentially inappropriate length which could increase dislodgement risk.
Intensive Care Society of …
Naiya Diarra
Historic (No Identified Response)
Relevant patient information was inaccessible to clinicians due to being stored in disparate record systems, highlighting systemic failures in inter-NHS record sharing.
National Institute for Health …
Geoffrey Parry
All Responded
Critical ECG test results were unavailable pre-surgery due to systemic record management issues. An unlabelled intravenous line was accidentally disconnected, highlighting a lack of clear …
Cardiff and Vale University …
Edward Gascoigne
All Responded
Relevant patient information was inaccessible to clinicians due to being stored in disparate record systems, highlighting systemic failures in inter-NHS record sharing.
Department of Health and …
Peter Furness
All Responded
The care home lacked a documented process for escalating incidents and concerns to trigger multi-disciplinary team meetings for reviewing vulnerable residents' risk assessments and care …
Nant y Gaer Hall …
Rosina Drury
Historic (No Identified Response)
The absence of a pre-operative orthogeriatric review for patients with femoral neck fractures risks inappropriate cemented hemiarthroplasty, potentially leading to fatal bone cement implantation syndrome.
Kings College Hospital
Charles Rayner
Historic (No Identified Response)
The highway crossover point lacks a deceleration lane and clear signage, forcing westbound traffic to slow dangerously in the outside lane for a right turn, …
Highways England
John Lomas
All Responded
Inadequate risk assessment of river conditions, lack of essential safety protocols for white water rafting (e.g., training, safety kayak, appropriate raft capacity), and poor communication …
Sports Camp Tirol
Kenneth McCurdy and Mary McCurdy
All Responded
The absence of clear signage at a central reservation gap fails to indicate prohibited right turns or U-turns for east-bound vehicles, creating a significant highway …
Highways England
Jean Hannon
All Responded
A critical diagnosis (autonomic dysreflexia) was not sufficiently highlighted in medical records, leading to a consultant's unawareness during a later admission and potentially inappropriate management.
East Lancashire Healthcare NHS …
Parv Patel
All Responded
The current PEWS scores are not aligned with research on child illness and may dangerously distract doctors from recognising seriously ill children despite low scores.
Department of Health and …
Ethan Johnson
All Responded
There was a critical lack of leadership and support for junior staff managing an abnormal CTG trace, compounded by a hierarchical system preventing timely consultant …
Milton Keynes Hospital