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 103 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 |
| 28 Sep 2015 |
Tania Hristova
The patient received antidepressant medication for over five years without adequate review and was not offered additional psychological …
|
New Court Surgery | All Responded | 1/1 |
| 28 Sep 2015 |
Harry Pryal
A significant lack of recorded medical advice between trusts, conflicting interpretations of service agreements, and failure to hold …
|
5 Boroughs Partnership NHS Trust Department of Health and Social … Wigan Borough Clinical Commissioning Group | All Responded | 4/3 |
| 28 Sep 2015 |
John Roberts
The current junction design encourages dangerous pedestrian crossings over the central reservation due to an unclear, distant designated …
|
Highways Agency | Historic (No Identified Response) | 0/1 |
| 25 Sep 2015 |
Violet Cloudsdale
The care home lacked risk assessments and consent for wheelchair lap-belt use, and unclear guidance on their application …
|
Care Quality Commission Risedale Estates Limited | Historic (No Identified Response) | 0/2 |
| 23 Sep 2015 |
Dorothy Delaney
The concurrent prescription of antiplatelet and anticoagulant medications without specialist advice contradicted national guidelines, significantly increasing haemorrhage risk, …
|
Alexander House Health Centre | Historic (No Identified Response) | 0/1 |
| 22 Sep 2015 |
Emma Waring
The absence of compulsory automatic water suppression systems in residential properties, especially for vulnerable individuals, represents a significant …
|
Department for Communities and Local … | All Responded | 1/1 |
| 22 Sep 2015 |
Stuart Knight
Significant and unacceptable delays in ambulance dispatch occurred for an unconscious patient with a serious head injury, potentially …
|
East Midlands Ambulance Services | All Responded | 1/1 |
| 22 Sep 2015 |
William Harnell
Significant national delays in X-ray reporting due to a shortage of qualified radiologists pose a risk to patient …
|
Department of Health and Social … Plymouth Hospitals NHS Trust Social Services Truro Cornwall | All Responded | 3/3 |
| 18 Sep 2015 |
Christianne Shepherd
Systemic failures include a lack of central register for hotel safety data, poor tour operator collaboration, insufficient carbon …
|
Unknown | 0/0 | |
| 18 Sep 2015 |
Liam Smith
Mandatory ACCT procedures for self-harm risk were not followed, critical medical information was poorly disseminated within the prison, …
|
Governor HMP Hewell Worcestershire Health and Care Trust | Partially Responded | 1/2 |
| 17 Sep 2015 |
Lee Bates
A critical lack of communication between psychiatry and sleep apnoea specialists, along with inadequate guidance and monitoring protocols …
|
Guys and St Thomas NHS … Cambian Group | Partially Responded | 1/2 |
| 17 Sep 2015 |
Fiona Lewis
There's a concern about ensuring healthcare professionals are adequately trained in resuscitation and can respond appropriately to patient …
|
Ipswich Hospital | Historic (No Identified Response) | 0/1 |
| 16 Sep 2015 |
David Charles
Street lighting was switched off on a dark night, significantly reducing pedestrian visibility and contributing to a fatal …
|
Essex Highways Agency | Historic (No Identified Response) | 0/1 |
| 16 Sep 2015 |
Adil Habib
Lack of specific gate location information for prisons during 999 calls, compounded by London Ambulance Service's system not …
|
National Offender Management Service London Ambulance Service NHS Trust HMP Pentonville | Partially Responded | 2/3 |
| 15 Sep 2015 |
Karen Clayton
The road layout has insufficient segregation for mixed traffic, with a confusing contra-flow cycle lane and unclear signage, …
|
Trafford Metropolitan Borough Council | All Responded | 1/1 |
| 14 Sep 2015 |
Anthony Cleveland
A gym lacked immediate problem recognition, adequate resuscitation, risk assessments for users, qualified first aiders, and formal national …
|
Health and Safety Executive | Historic (No Identified Response) | 0/1 |
| 14 Sep 2015 |
Stephen O’Malley
Rescue was delayed due to the standby diver being unable to locate a critical harness c-clip, as pre-dive …
|
SubCPartner | All Responded | 2/1 |
| 11 Sep 2015 |
George Ainsworth
A dangerous road junction has blind spots and limited driver visibility, creating a "pinch point" for large vehicles …
|
Unknown | 0/0 | |
| 11 Sep 2015 |
Ronald Bonfield
Inconsistent practices for monitoring district nurse compliance with delegated INR testing across GP surgeries create a risk of …
|
Unknown | 0/0 | |
| 11 Sep 2015 |
Thomas Nicholls
Care staff lacked training in PEG feeding, including patient mobility, leading to an incident of vomiting that was …
|
Unknown | 0/0 | |
| 8 Sep 2015 |
Ian Emsley
Inadequate formal guidance for healthcare staff on assessing re-offending and escape risk contributed to delays in compassionate release …
|
Unknown | 0/0 | |
| 8 Sep 2015 |
David Efemena
A cadet training site lacked defibrillators and AED-trained first aiders, with challenging emergency access. There were also ineffective …
|
Unknown | 0/0 | |
| 8 Sep 2015 |
Andrew Frere
A national prison instruction for 24-hour doctor review is impracticable and ignored. Case managers also fail to read …
|
Unknown | 0/0 | |
| 8 Sep 2015 |
Craig Chappell
Inadequate information sharing and a lack of formal mechanisms for communicating family concerns hindered support. Prison staff also …
|
Unknown | 0/0 | |
| 4 Sep 2015 |
Mary James
Inadequate INR monitoring, uncertainty regarding Warfarin intake, and poor communication between healthcare providers led to unadjusted anticoagulation therapy …
|
Unknown | 0/0 | |
| 3 Sep 2015 |
Kala Skinner
Clinical advisors missed critical 'red flags' and gave inappropriate advice due to inadequate training, mentoring, and auditing, leading …
|
Unknown | 0/0 | |
| 3 Sep 2015 |
May Hall
Care home staff lacked awareness and clear training on fall reporting policies and how to contact emergency services, …
|
Unknown | 0/0 | |
| 2 Sep 2015 |
Rosalind Baird
There is no formal national monitoring scheme for inexperienced surgeons, despite the existence of effective local models, risking …
|
Unknown | 0/0 | |
| 1 Sep 2015 |
John Robinson
The unavailability of a psychiatric bed for Mr Robinson led to his deteriorating condition and death, raising concerns …
|
Unknown | 0/0 | |
| 1 Sep 2015 |
Darren Browne
A vulnerable adult with high suicide risk was prevented from contacting family, a decision that failed to properly …
|
Unknown | 0/0 | |
| 28 Aug 2015 |
Isabel Richardson
The school's Pastoral Team lacked clear purpose, operational structure, and adequate staff training, rendering it an insufficiently robust …
|
Unknown | 0/0 | |
| 27 Aug 2015 |
Frederick Sutton
Suboptimal staffing, poor staff training in drug administration and cardiac arrest response, unread nursing notes, incompatible computer systems, …
|
Unknown | 0/0 | |
| 27 Aug 2015 |
Eliza Simpson
The care home lacked a system for renewing deprivation of liberty orders, risking unauthorized detention. The absence of …
|
Unknown | 0/0 | |
| 20 Aug 2015 |
Andrew Roberts
Inaccurate and delayed completion of the Transfer of Care Form by a doctor prevented critical patient information from …
|
Unknown | 0/0 | |
| 20 Aug 2015 |
Joyce Plested
The unsafe positioning of a zebra crossing too close to a mini-roundabout creates a high-risk junction for pedestrians …
|
Unknown | 0/0 | |
| 20 Aug 2015 |
Elsie Clarke
Significant systemic failures in care home staff training, including emergency protocols, resident observation, record-keeping, and handover procedures, alongside …
|
Unknown | 0/0 | |
| 20 Aug 2015 |
Sharon Henshall
The absence of a VTE risk assessment tool in the Emergency Department for patients discharged with lower limb …
|
Unknown | 0/0 | |
| 19 Aug 2015 |
Barry Pike
The specific matters of concern are detailed in an external report by Dr Stephen Hoole, which was not …
|
Unknown | 0/0 | |
| 18 Aug 2015 |
Stephen Richardson
Nursing staff consistently failed to adhere to critical dietary and drink restrictions for a patient with Down's Syndrome, …
|
University Hospital of North Staffordshire | All Responded | 1/1 |
| 17 Aug 2015 |
Ian Morley
A patient's deteriorating condition failed to trigger a necessary fresh risk assessment, compounded by inadequate fire risk management …
|
Adult Social Services Greenrod Place | Historic (No Identified Response) | 0/2 |
| 12 Aug 2015 |
Thelma Jones
The provided text only states the report concerns the Acute Medical Unit (AMU) where the deceased was admitted, …
|
Brighton and Sussex University Hospitals … | All Responded | 1/1 |
| 12 Aug 2015 |
Dean Joseph
Inconsistent understanding of armed containment, lack of trained negotiator guidance for first responders, and sub-optimal post-incident procedures undermined …
|
Metropolitan Police Service | All Responded | 1/1 |
| 12 Aug 2015 |
Ben Hiscox
The distance between the football touchline and clubhouse fell below FA safety recommendations, placing players at risk of …
|
Unknown | 0/0 | |
| 12 Aug 2015 |
Eileen Smith
The report detailed gross failings of nursing care for a patient with a learning disability and highlighted the …
|
Department of Health and Social … | All Responded | 1/1 |
| 11 Aug 2015 |
Julia Hayward
Discharged mental health patients' care plans, especially those involving family obligations, were only verbally agreed and not documented …
|
Department of Health and Social … | All Responded | 1/1 |
| 11 Aug 2015 |
John Hills
Paraffin-based emollient creams lacked fire hazard warnings on labels and prescriptions, and risks were not communicated to a …
|
Staffordshire Fire and Rescue Service National Patient Safety Agency | Historic (No Identified Response) | 0/2 |
| 10 Aug 2015 | Lorraine Bird | Unknown | 0/0 | |
| 7 Aug 2015 |
Kathleen Neville
The absence of a Medication Reconciliation policy allowed medication errors to go undetected for too long, posing a …
|
NHS Wales Welsh Assembly Government | Historic (No Identified Response) | 0/2 |
| 7 Aug 2015 |
James Adams
A severe shortage of acute psychiatric beds in Cornwall forces inappropriate detention in police cells or distant out-of-county …
|
Curnow Commissioning Group NHS England Department of Health and Social … | Partially Responded | 2/3 |
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 …
Tania Hristova
All Responded
The patient received antidepressant medication for over five years without adequate review and was not offered additional psychological therapies such as counselling or CBT.
New Court Surgery
Harry Pryal
All Responded
A significant lack of recorded medical advice between trusts, conflicting interpretations of service agreements, and failure to hold mandated liaison meetings resulted in poor inter-trust …
5 Boroughs Partnership NHS …
Department of Health and …
Wigan Borough Clinical Commissioning …
John Roberts
Historic (No Identified Response)
The current junction design encourages dangerous pedestrian crossings over the central reservation due to an unclear, distant designated crossing, posing significant risk.
Highways Agency
Violet Cloudsdale
Historic (No Identified Response)
The care home lacked risk assessments and consent for wheelchair lap-belt use, and unclear guidance on their application raised concerns about unlawful restraint, contributing to …
Care Quality Commission
Risedale Estates Limited
Dorothy Delaney
Historic (No Identified Response)
The concurrent prescription of antiplatelet and anticoagulant medications without specialist advice contradicted national guidelines, significantly increasing haemorrhage risk, especially given the patient's amyloid angiopathy.
Alexander House Health Centre
Emma Waring
All Responded
The absence of compulsory automatic water suppression systems in residential properties, especially for vulnerable individuals, represents a significant fire safety risk.
Department for Communities and …
Stuart Knight
All Responded
Significant and unacceptable delays in ambulance dispatch occurred for an unconscious patient with a serious head injury, potentially prejudicing the outcome.
East Midlands Ambulance Services
William Harnell
All Responded
Significant national delays in X-ray reporting due to a shortage of qualified radiologists pose a risk to patient care across the UK.
Department of Health and …
Plymouth Hospitals NHS Trust
Social Services Truro Cornwall
Christianne Shepherd
Unknown
Systemic failures include a lack of central register for hotel safety data, poor tour operator collaboration, insufficient carbon monoxide awareness, and delegation of critical health …
Liam Smith
Partially Responded
Mandatory ACCT procedures for self-harm risk were not followed, critical medical information was poorly disseminated within the prison, and limited healthcare interaction with high-risk drug …
Governor HMP Hewell
Worcestershire Health and Care …
Lee Bates
Partially Responded
A critical lack of communication between psychiatry and sleep apnoea specialists, along with inadequate guidance and monitoring protocols for OSA patients receiving sedative medication, creates …
Guys and St Thomas …
Cambian Group
Fiona Lewis
Historic (No Identified Response)
There's a concern about ensuring healthcare professionals are adequately trained in resuscitation and can respond appropriately to patient collapse.
Ipswich Hospital
David Charles
Historic (No Identified Response)
Street lighting was switched off on a dark night, significantly reducing pedestrian visibility and contributing to a fatal collision, despite drivers being unable to avoid …
Essex Highways Agency
Adil Habib
Partially Responded
Lack of specific gate location information for prisons during 999 calls, compounded by London Ambulance Service's system not uniformly supporting alternative gate selection across all …
National Offender Management Service
London Ambulance Service NHS …
HMP Pentonville
Karen Clayton
All Responded
The road layout has insufficient segregation for mixed traffic, with a confusing contra-flow cycle lane and unclear signage, creating a dangerous environment compounded by weak …
Trafford Metropolitan Borough Council
Anthony Cleveland
Historic (No Identified Response)
A gym lacked immediate problem recognition, adequate resuscitation, risk assessments for users, qualified first aiders, and formal national guidance on fitness centre safety.
Health and Safety Executive
Stephen O’Malley
All Responded
Rescue was delayed due to the standby diver being unable to locate a critical harness c-clip, as pre-dive protocol checks do not include verifying its …
SubCPartner
George Ainsworth
Unknown
A dangerous road junction has blind spots and limited driver visibility, creating a "pinch point" for large vehicles and putting pedestrians at risk, compounded by …
Ronald Bonfield
Unknown
Inconsistent practices for monitoring district nurse compliance with delegated INR testing across GP surgeries create a risk of unmonitored over-anticoagulation.
Thomas Nicholls
Unknown
Care staff lacked training in PEG feeding, including patient mobility, leading to an incident of vomiting that was not reported or investigated, indicating systemic failures …
Ian Emsley
Unknown
Inadequate formal guidance for healthcare staff on assessing re-offending and escape risk contributed to delays in compassionate release or transfer decisions for terminally ill prisoners.
David Efemena
Unknown
A cadet training site lacked defibrillators and AED-trained first aiders, with challenging emergency access. There were also ineffective communication checks between staff and cadets at …
Andrew Frere
Unknown
A national prison instruction for 24-hour doctor review is impracticable and ignored. Case managers also fail to read ongoing observations during ACCT reviews, risking missed …
Craig Chappell
Unknown
Inadequate information sharing and a lack of formal mechanisms for communicating family concerns hindered support. Prison staff also lacked sufficient guidance on supporting potential abuse …
Mary James
Unknown
Inadequate INR monitoring, uncertainty regarding Warfarin intake, and poor communication between healthcare providers led to unadjusted anticoagulation therapy for a dementia patient, missing a critical …
Kala Skinner
Unknown
Clinical advisors missed critical 'red flags' and gave inappropriate advice due to inadequate training, mentoring, and auditing, leading to failures in recognising serious conditions and …
May Hall
Unknown
Care home staff lacked awareness and clear training on fall reporting policies and how to contact emergency services, indicating a need for regular, confirmed training.
Rosalind Baird
Unknown
There is no formal national monitoring scheme for inexperienced surgeons, despite the existence of effective local models, risking patient safety during surgical procedures.
John Robinson
Unknown
The unavailability of a psychiatric bed for Mr Robinson led to his deteriorating condition and death, raising concerns about insufficient mental health resources in the …
Darren Browne
Unknown
A vulnerable adult with high suicide risk was prevented from contacting family, a decision that failed to properly balance his acute needs and risks against …
Isabel Richardson
Unknown
The school's Pastoral Team lacked clear purpose, operational structure, and adequate staff training, rendering it an insufficiently robust system to address student problems.
Frederick Sutton
Unknown
Suboptimal staffing, poor staff training in drug administration and cardiac arrest response, unread nursing notes, incompatible computer systems, and inaccurate patient information contributed to systemic …
Eliza Simpson
Unknown
The care home lacked a system for renewing deprivation of liberty orders, risking unauthorized detention. The absence of CCTV also hindered investigation into an absconding …
Andrew Roberts
Unknown
Inaccurate and delayed completion of the Transfer of Care Form by a doctor prevented critical patient information from being immediately available to custody nurses.
Joyce Plested
Unknown
The unsafe positioning of a zebra crossing too close to a mini-roundabout creates a high-risk junction for pedestrians and drivers, and a simple relocation would …
Elsie Clarke
Unknown
Significant systemic failures in care home staff training, including emergency protocols, resident observation, record-keeping, and handover procedures, alongside deficiencies in Out of Hours doctors' practices.
Sharon Henshall
Unknown
The absence of a VTE risk assessment tool in the Emergency Department for patients discharged with lower limb immobilisation, coupled with varied national guidance, creates …
Barry Pike
Unknown
The specific matters of concern are detailed in an external report by Dr Stephen Hoole, which was not provided here.
Stephen Richardson
All Responded
Nursing staff consistently failed to adhere to critical dietary and drink restrictions for a patient with Down's Syndrome, despite explicit instructions, raising significant risks of …
University Hospital of North …
Ian Morley
Historic (No Identified Response)
A patient's deteriorating condition failed to trigger a necessary fresh risk assessment, compounded by inadequate fire risk management at the care facility.
Adult Social Services
Greenrod Place
Thelma Jones
All Responded
The provided text only states the report concerns the Acute Medical Unit (AMU) where the deceased was admitted, without specifying the issues or failures.
Brighton and Sussex University …
Dean Joseph
All Responded
Inconsistent understanding of armed containment, lack of trained negotiator guidance for first responders, and sub-optimal post-incident procedures undermined the investigation and public confidence.
Metropolitan Police Service
Ben Hiscox
Unknown
The distance between the football touchline and clubhouse fell below FA safety recommendations, placing players at risk of injury or death, with no action taken …
Eileen Smith
All Responded
The report detailed gross failings of nursing care for a patient with a learning disability and highlighted the risk of making assumptions about health based …
Department of Health and …
Julia Hayward
All Responded
Discharged mental health patients' care plans, especially those involving family obligations, were only verbally agreed and not documented or provided, leading to critical misunderstandings.
Department of Health and …
John Hills
Historic (No Identified Response)
Paraffin-based emollient creams lacked fire hazard warnings on labels and prescriptions, and risks were not communicated to a known smoker, highlighting a gap in NPSA …
Staffordshire Fire and Rescue …
National Patient Safety Agency
Lorraine Bird
Unknown
Kathleen Neville
Historic (No Identified Response)
The absence of a Medication Reconciliation policy allowed medication errors to go undetected for too long, posing a significant risk of future deaths, particularly in …
NHS Wales
Welsh Assembly Government
James Adams
Partially Responded
A severe shortage of acute psychiatric beds in Cornwall forces inappropriate detention in police cells or distant out-of-county transfers, causing patient deterioration and misallocating valuable …
Curnow Commissioning Group
NHS England
Department of Health and …