PFD Response Tracker

Prevention of Future Deaths

Total: 1,340 Responded: 0 No identified response (past 2 years): 0 Pending: 0 Historic with no identified response: 1,340

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

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

1 report include a non-response confirmed by the Chief Coroner. Show only confirmed

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1,340 reports · Page 11 of 27

Date	Deceased	Addressee(s)	Status	Responses
25 Jul 2018	Robert Wrinch The pathology department lacked systems for tracking samples and documenting clinician communications, causing delays and unclear chronologies. Incompatible …	Department for Health Royal College of Pathologists Stockport NHS Trust	Historic (No Identified Response)	0/3
25 Jul 2018	Jane Parker Care home staff had poor understanding of modified diets and lacked systems for correct food preparation and marking. …	Care Quality Commission	Historic (No Identified Response)	0/1
20 Jul 2018	Ruth Perkins A high-risk patient was discharged to a care home with insufficient staffing levels for her needs, particularly lacking …	Department for Health	Historic (No Identified Response)	0/1
19 Jul 2018	Ronald Harman The provided text indicates general concerns about matters revealed during the inquest, suggesting a risk of future deaths …	Brighton and Sussex University Hospital …	Historic (No Identified Response)	0/1
19 Jul 2018	Jeroen Ensink Police failures included not creating mental health alerts, inaccurate record-keeping regarding injuries and force, and failing to inform …	Metropolitan Police Service	Historic (No Identified Response)	0/1
18 Jul 2018	Mohammed Ahmed	Department for Health Manchester University NHS Trust RCOG	Historic (No Identified Response)	0/3
18 Jul 2018	Ellie Knowles A venue maintains a license for high-risk events but lacks a robust internal protocol requiring consultation with police …	Hoults Limited Shindig Events Limited	Historic (No Identified Response)	0/2
16 Jul 2018	Sheila Ridgway A lack of systemic communication between specialty consultants prevents identifying and documenting potential ongoing risks when patients receive …	Care Quality Commission Manchester University NHS Trust NHS England Stockport NHS Trust Alexandra Hospital	Historic (No Identified Response)	0/5
11 Jul 2018	Rita Giles The provided text indicates general concerns about matters revealed during the inquest, suggesting a risk of future deaths …	Brighton and Sussex University Hospital …	Historic (No Identified Response)	0/1
9 Jul 2018	Doris McCarthy Concerns persist about sensor system outages failing to alert staff to falls and inadequate safeguards for residents prone …	Baycroft Care Homes	Historic (No Identified Response)	0/1
29 Jun 2018	Lindsey Tyrrell Routine testing for toxoplasmosis was not performed on stem cell transplant patients with infection signs, and local learning …	Department of Health and Social … NHS England	Historic (No Identified Response)	0/2
29 Jun 2018	Ashley Notson There is no legal requirement for care home carers to have first aid training or to carry mobile …	Care Quality Commission Department of Health and Social …	Historic (No Identified Response)	0/2
29 Jun 2018	Daphne Penn Inadequate communication of steroid risks and family concerns, alongside prescribing errors, led to an inadvertent rapid steroid dose …	Rookery Medical Centre West Suffolk Hospital	Historic (No Identified Response)	0/2
26 Jun 2018	Margaret Evans Persistent issues with ambulance delays, emergency department overcrowding, and resource availability continue to pose significant risks to patient …	Welsh Ambulance Services NHS Trust	Historic (No Identified Response)	0/1
25 Jun 2018	Marjorie McMahon Significant ambulance response delays occurred for a high-priority patient due to high demand and insufficient resources, far exceeding …	Department of Health and Social … NHS England	Historic (No Identified Response)	0/2
25 Jun 2018	Sylvia Davies Virgin Care's delay in adopting new urgent care assessment standards and the failure to transcribe or retain crucial …	Coventry and Rugby Clinical Commissioning … Virgin care Coventry LLP	Historic (No Identified Response)	0/2
22 Jun 2018	Alexia Walenkaki Organisational failures, including the use of inappropriate wood in equipment and a lack of accountability for annual inspections …	Tower Hamlets Borough Council	Historic (No Identified Response)	0/1
19 Jun 2018	Derek Smith Poor communication between the District Nursing team, family members, and other agencies, alongside issues with nursing record availability, …	Virgin Care Services Limited	Historic (No Identified Response)	0/1
18 Jun 2018	Colin Johns There was inadequate communication and history-taking during mental health assessments, failing to record critical self-harm attempts, and insufficient …	Black Country NHS Foundation Trust	Historic (No Identified Response)	0/1
18 Jun 2018	Bryan Allsop Pilot licensing does not mandate instruction and testing in partial engine power loss scenarios for light aircraft, despite …	Department for Transport	Historic (No Identified Response)	0/1
15 Jun 2018	Sneh Chaudhry Drug confusion due to similar vial appearance between Fungizone and Ambisone, combined with passive nursing checks, created a …	NHS England	Historic (No Identified Response)	0/1
13 Jun 2018	Karen Wiggins Multi-storey car parks in Swindon lack physical barriers or warning notices, despite previous suicidal falls, failing to prevent …	Swindon Borough Council	Historic (No Identified Response)	0/1
7 Jun 2018	Kevin Freely Insufficient awareness and adherence to fire safety warnings regarding paraffin-based emollients, smoking in bed, and air-flow mattresses, combined …	Care Quality Commission Skillsforcare Home Office	Historic (No Identified Response)	0/3
6 Jun 2018	William Bartram Unclear processes for repeat blood samples in babies, failure to highlight abnormal test results, and inadequate discharge advice …	Barts Health NHS Trust	Historic (No Identified Response)	0/1
6 Jun 2018	Ester Wood Ongoing, systemic problems with ambulance delays, emergency department access, and patient flow continue to place lives at risk, …	Welsh Ambulance Services NHS Trust	Historic (No Identified Response)	0/1
4 Jun 2018	John Derwent Excessive waiting times for CBT (12 months) due to insufficient capacity and ineffective escalation mechanisms between commissioning and …	Pennine NHS Trust Tameside and Glossop Clinical Commissioning …	Historic (No Identified Response)	0/2
31 May 2018	Elaine Horrocks Unsafe access methods to the cellar and insufficient guarding of cellar steps against accidental public entry pose a …	Brewery	Historic (No Identified Response)	0/1
29 May 2018	Joan Lunt Deficiencies in electronic record-keeping by agency staff, including unidentified entries, compromise record integrity and continuity of care, despite …	Harbour Healthcare Limited	Historic (No Identified Response)	0/1
25 May 2018	Neil Jones Repeated fatal road traffic collisions at a specific site, despite speed limit reduction, highlight the urgent need for …	Warwickshire County Council	Historic (No Identified Response)	0/1
25 May 2018	Robin Richards A shortage of suitable supported accommodation, coupled with poor communication, inadequate discharge planning, and insufficient risk assessment processes, …	Department of Health and Social … Somerset NHS Trust	Historic (No Identified Response)	0/2
24 May 2018	Rosalind Flett Ambiguity in the Trust's search policy created a gap between "advanced" and "intimate" searches, preventing staff from conducting …	Department of Health and Social …	Historic (No Identified Response)	0/1
23 May 2018	Grahame Searby The mental health team's lack of access to GP databases (EMIS) hinders comprehensive information gathering, necessitating a review …	South West Yorkshire NHS Trust	Historic (No Identified Response)	0/1
22 May 2018	Michael Berry A "reduced risk" healthcare cell contained a clear ligature point, an inwardly opening window, indicating a design flaw …	HM Prison Bedford	Historic (No Identified Response)	0/1
22 May 2018	Andrew Crane Unclear guidance for prison officers on initiating emergency calls for chest pain, and failure to update ambulance services …	HMP Ryehill	Historic (No Identified Response)	0/1
21 May 2018	Caroline Scott Out-of-hours emergency mental health services are inadequate, and medical staff do not fully understand the emergency referral policy.	Central and North West London …	Historic (No Identified Response)	0/1
21 May 2018	Michalla Sweeting Concerns were raised about inadequate handover procedures for detox patients, including nurses' record review responsibilities and the timing …	Bristol Community Health	Historic (No Identified Response)	0/1
21 May 2018	Alfie Scambler-Holt The absence of a national PEWS scoring system creates inconsistency across trusts, leading to varied escalation processes and …	NHS England	Historic (No Identified Response)	0/1
20 May 2018	Mwitumwa Ngenda Concerns focus on the urgent need for preventative measures and design changes on Scammonden Bridge to prevent future …	Calderdale Council	Historic (No Identified Response)	0/1
18 May 2018	Graeme Mathieson GPs face unmanageable time constraints without proper triage, and professionals are confused about mental health patient pathways, especially …	NHS England	Historic (No Identified Response)	0/1
17 May 2018	Bernard Fagg Concerns exist over whether patients undergoing CT scans with contrast and subsequent nil-by-mouth procedures should receive intravenous fluids, …	Medway NHS Trust	Historic (No Identified Response)	0/1
14 May 2018	Philip Ashton Medication errors occurred due to flawed procedures, staff were unprepared for emergencies, and vital medical history was inaccessible …	PJ Care	Historic (No Identified Response)	0/1
14 May 2018	Hans-Peter Schmidt Lack of barrier maintenance, absent permanent barriers, inadequate international warning signs, and insufficient staff training at cliff hot …	Cornwall Council Heritage Attractions Ltd Lands End Resort	Historic (No Identified Response)	0/3
12 May 2018	Charles Grainger Systemic barriers prevented social workers from sharing crucial falls history with multi-agencies, and investigations failed to adequately review …	Milford House Care Home Derbyshire County Council NHS Southern Derbyshire Clinical Commissioning …	Historic (No Identified Response)	0/3
11 May 2018	Thomas Ratchford Carers improperly used a hoist for pressure relief without expert advice, highlighting insufficient training in moving/handling and pressure …	Elizabeth House (Oldham) Limited	Historic (No Identified Response)	0/1
9 May 2018	Lewis Colgan Inadequate supervision of care coordinators, incompatible caseloads, and staff changes compromised mental health care continuity and engagement. Lack …	Oxford Health NHS Trust	Historic (No Identified Response)	0/1
9 May 2018	Joan Hanratty The system for providing antibiotics and steroids to COPD patients on request lacks explicit advice for them to …	Denton Medical Centre	Historic (No Identified Response)	0/1
30 Apr 2018	Matthew Fulleylove Operatives work in dangerously restricted spaces near rotating industrial saws, and machines continue to pass with insufficient clearance, …	Treanor Pujol Limited	Historic (No Identified Response)	0/1
26 Apr 2018	Yazin Elhjaje Safety-netting advice provided upon discharge focused solely on headaches, failing to include information about the differential diagnosis of …	University Hospitals Bristol NHS Trust	Historic (No Identified Response)	0/1
20 Apr 2018	Novia Delima Emergency Department demand prevented meeting triage targets, early paediatrician involvement for very young children was not ensured, and …	Mayor of Greater Manchester NHS England Department of Health and Social …	Historic (No Identified Response)	0/3
19 Apr 2018	Amanda Spark Concerns arose regarding a patient's decision to change her medication regime while under crisis team care, implying potential …	Dorset University NHS Trust	Historic (No Identified Response)	0/1

Robert Wrinch